This week in Medicare updates—11/17/2021
Medicare Advantage Compliance Audit of Specific Diagnosis Codes that UPMC Health Plan, Inc., Submitted to CMS
On November 8, the OIG published a Review of whether select diagnosis codes that UPMC Health Plan, Inc., a Medicare Advantage organization, submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by selecting 280 unique enrollee-years with high risk diagnosis codes for which UPMC received higher payments in 2015-2016. The OIG found that the diagnosis codes UPMC submitted for 194 of the 280 enrollee-years did not comply with federal requirements as they were not supported by the medical records. UPMC received net overpayments of $6.4 million from 2015-2016 as a result of these errors.
The OIG recommended that, in addition to refunding the federal government for the $6.4 million in net overpayments and identifying and returning any similar overpayments, UPMC investigate existing compliance procedures to identify areas where improvements could be made to ensure that these diagnosis codes comply with federal requirements. UPMC disagreed with the OIG’s findings and recommendations, questioned the audit methodology and the qualifications of the independent medical reviewer, and said the OIG did not calculate overpayments in accordance with CMS requirements. The OIG revised some of its findings after reviewing UPMC’s comments but stands by its audit methodology.
Updated Provider Self-Disclosure Settlements
On November 9, the OIG published an updated List of Provider Self-Disclosure Settlements with the following organizations:
- On October 5, RMS Lifeline and Vascular Surgery Associates, of Richmond, VA, reached a $79,668 settlement with the OIG to resolve allegations that it submitted false certifications about physicians meeting Meaningful Use Program requirements and that it submitted claims for physician visits under CPT code 99212 that should have been submitted as nurse visits under CPT code 99211.
- On October 7, Texas Center for Infectious Disease Associates, of Texas, reached a $609,579.93 settlement agreement with the OIG to resolve allegations that it billed Part D for entire vials of certain drugs when only part of the vial was dispensed and overbilled Part D for dispensed doses.
- On October 7, Friends Extended Care Center, of Ohio, reached a $101,691.20 settlement agreement with the OIG to resolve allegations that it submitted claims for services provided by an unlicensed individual.
- On October 7, Advanced OrthoPro, of Indiana, reached a $7.1 million settlement agreement with the OIG to resolve allegations that it submitted false claims for durable medical equipment dispensed at AOP locations not enrolled as DME providers and used an enrollment number of a different AOP location for the claims.
- On October 15, Suburban Crossroads Counseling (SPCC), of Maryland, reached a $65,000 settlement agreement with the OIG to resolve allegations that it submitted improper claims using SPCC’s NPI for mental health counseling services provided by LCPCs incident-to LCSWs when such services were not covered by Medicare or Maryland Medicaid.
- On October 27, Pettis County Ambulance District, of Missouri, reached a $690,833.37 settlement agreement with the OIG to resolve allegations that it submitted false claims to federal health care programs for emergency transports when they were actually non-emergent hospital-to-hospital transports.
The OIG also reached new settlements with facilities that employed individuals they knew or should have known were excluded from federal healthcare programs, including:
- Cottage Hospital
- Thomas Jefferson University Hospitals
- Stonebridge of Gurnee
- CODA
Updated List of Excluded Individuals and Entities (LEIE)
On November 9, the OIG updated its LEIE with an updated LEIE database for download and lists of October 2021 exclusions, reinstatements, and profile corrections.
Comment Request Correction: Medicare-Funded GME Residency Positions in Accordance with Section 126 of the Consolidated Appropriations Act, 2020
On November 9, CMS published a Correction Notice in the Federal Register to correct a section of a Comment Request notice for an information collection titled “Medicare-Funded GME Residency Positions in Accordance with Section 126 of the Consolidated Appropriations Act, 2020.” CMS is correcting information in the “use” section of the notice.
The related comment period remains in effect until December 21.
Comment Request: Patient-Reported Indicator Survey (PaRIS); Medicare Advantage and Prescription Drug Plan Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Field Test; more
On November 9, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Patient-Reported Indicator Survey (PaRIS)
- Medicare Advantage and Prescription Drug Plan Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Field Test
- Medicaid Drug Rebate Program Labeler Reporting Format
Comments are due by January 10, 2022.
2022 Annual Update to the Therapy Code List
On November 10, CMS published Medicare Claims Processing Transmittal 11118, which rescinds and replaces Transmittal 11036, dated October 13, 2021, to make updates to the background/policy section in the CR and to update the website link in BR 12446.2. This transmittal is no longer sensitive and may now be posted to the internet. The original transmittal was published regarding the annual updates to the list of codes that sometimes or always describe therapy services.
CMS published MLN Matters 12446 on the same date to accompany the transmittal.
Effective date: January 1, 2022
Implementation date: January 3, 2022
NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds
On November 10, CMS published Medicare Claims Processing Transmittal 11119 and Medicare National Coverage Determinations Transmittal 11119, which rescind and replace Claims Processing Transmittal 10981 and National Coverage Determinations Transmittal 10981, dated September 8, 2021, to change multiple business requirements, revise messaging in some business requirements, revise verbiage in other business requirements, and extend the implementation date. All revisions are associated with the Claims Processing Manual. The original transmittal was published regarding implementation for coverage of autologous platelet-rich plasma (PRP) infusions for the treatment of chronic non-healing diabetic wounds.
On September 15, CMS published MLN Matters 12403 to accompany the transmittals.
Effective date: April 13, 2021
Implementation date: November 23, 2021 - for MACs; January 3, 2022 - Shared Systems
Advisory Opinion 21-15
On November 10, the OIG published an Advisory Opinion regarding whether a pain management company’s proposal to retain net profits from services provided by an employed CRNA pursuant to a reassignment of billing rights would be grounds for the imposition of sanctions under civil monetary penalties related to the anti-kickback statute. The CRNA reassigned the right to receive reimbursement for anesthesia services they perform as part of their employment agreement, and in turn receives a salary from the pain management company. These services are provided at the pain management practice’s office and an ambulatory surgical center.
The OIG said that while the arrangement would generate prohibited remuneration under the federal anti-kickback statute, the OIG would not impose administrative sanctions on the requestor. One stream of remuneration under the proposed arrangement is protected by the employment safe harbor, and the other stream of remuneration is a straightforward employment arrangement which presents a low risk of fraud and abuse under the anti-kickback statute.
Updated Corporate Integrity Agreement Documents
On November 10, the OIG published information on a new Corporate Integrity Agreement with the following entity:
Repealing the Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule
On November 12, CMS published a draft copy of a Final Rule which repeals the MCIT and Definition of “Reasonable and Necessary” final rule that was published January 14, 2021, and previously delayed as of March 17, 2021. CMS said it decided to repeal the final rule because of concerns about insufficient safeguards to ensure safety and effectiveness standards align with Medicare coverage standards. CMS said it will continue to explore coverage process improvements that will enhance access to innovative and beneficial medical devices while maintaining appropriate health and safety protections.
CMS published a Press Release regarding the rule, and the rule is scheduled to be published in the Federal Register on November 15.
This rule is effective December 15, 2021.
Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes
On November 12, CMS published a Memorandum to state survey agency directors regarding steps CMS is taking to help the state survey agencies to address the backlog of complaint and recertification surveys. This includes revisions to criteria for COVID-19 Focused Infection Control Surveys, guidance on resuming recertification surveys, and temporary guidance and flexibilities related to complaint investigations. CMS is also asking survey agency to be aware of areas that may have fallen through the cracks during the limited oversight resulting from the PHE, especially regarding compliance with requirements for nursing services, inappropriate use of antipsychotic medications, and additional areas of concern highlighted at the end of the memo.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
Nursing Home Visitation - COVID-19
On November 12, CMS revised a Memorandum to state survey agency directors, originally dated September 17, 2020, to revise information about visitation. CMS notes that visitation is now allowed for all nursing home residents at all times and revised the memo in numerous places to describe that. The memo also discusses when to prohibit a visitor from entering the facility and what potential limitations may arise regarding visitation.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/CMS locations within 30 days of this memorandum.
Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities
On November 12, CMS revised a Memorandum to state survey agency directors, originally dated May 3, 2019, regarding guidance for hospitals on co-locating with other hospitals or healthcare facilities. The memo contains the guidance for evaluating compliance with Medicare Conditions of Participation related to shared space and services for hospitals co-located with other hospitals or health care entities, but there is no red text in the memo to indicate what, if anything, has been revised since the original publication of the memo.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/CMS locations within 30 days of this memorandum.