This week in Medicare updates—1/12/2022

January 12, 2022
Medicare Insider

COVID-19 Tests Drove Increase in Total Medicare Part B Spending on Lab Tests in 2020, Use of Non-COVID-19 Tests Decreased Significantly

On January 4, the OIG published a Data Brief regarding Medicare payment for lab tests under Part B in 2020. The OIG found that spending on non-COVID-19 lab tests declined from $7.7 billion in 2019 to $6.5 billion in 2020. However, Medicare Part B spent $1.5 billion on COVID-19 tests in 2020, which increased total spending on lab tests to $8 billion in 2020. The top test by spending was the rapid COVID-19 test (U0003), which accounted for $1.02 billion in spending for more than 10 million tests. The OIG said it is concerned about how the decline in volume for non-COVID-19 tests may impact beneficiary health. It noted that the decline in those tests coincided with the height of COVID-19-related economic shutdowns, and it is concerned that decline in tests may be representative of beneficiaries delaying or avoiding preventative healthcare screenings.


Updated Corporate Integrity Agreement Documents

On January 6, the OIG published information on closed Corporate Integrity Agreements with the following entities:

  • CVS Caremark Corporation, of Woonsocket, RI
  • Essex Group Management Corp. and Claflin Hill Corporation and Dartmouth House Nursing Home, Inc., and St. John’s Nursing Home, Inc., and Erlin Manor Nursing Home, Inc., and Westside Corporation, and Houghton Corporation, of Rowley, MA
  • Gamma Healthcare, Inc., of Poplar Bluff, MO
  • Health Concepts, Ltd., of Providence, RI
  • Prime Healthcare Services, Inc., etc. of Ontario, CA


Nursing Home Visitation FAQs

On January 6, CMS updated an FAQ regarding nursing home visitation guidance during the COVID-19 PHE. Updates include a reminder that states may take additional measures to make visitation safer, the need for facilities to document discussions with the health department and any actions they take to attempt to control COVID-19 transmission, new FAQs about visitation during the Omicron spike, and more.


Proposed Rule: Contract Year (CY) 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program

On January 6, CMS published a draft copy of a Proposed Rule regarding changes to Medicare Advantage (MA) and Part D for CY 2023. Proposals include a policy that would require Part D plans to apply all price concessions they receive from network pharmacies to the point of sale so beneficiaries can share in savings; changes to marketing and communications oversight to help detect and prevent deceptive marketing tactics used to enroll beneficiaries in MA and Part D plans; requirements for MA plans to comply with special requirements when there is a disaster declaration or emergency declaration that may disrupt access to health care; and more. 

CMS published a Fact Sheet and a Press Release on the rule on the same date. The rule is scheduled to be published in the Federal Register on January 12. Comments are due by March 7.


Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Healthfirst Health Plan, Inc., Submitted to CMS

On January 7, the OIG published a Review of whether select diagnosis codes that Healthfirst 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 240 unique enrollee-years with high risk diagnosis codes for which Healthfirst received higher payments in 2015-2016. The OIG found that the diagnosis codes Healthfirst submitted for 155 of the 240 enrollee-years did not comply with federal requirements as they were not supported by the medical records. Healthfirst received an estimated $5.2 million in net overpayments from 2015-2016 as a result of these errors.

The OIG recommended that, in addition to refunding the federal government for the $5.2 million in net overpayments and identifying and returning any similar overpayments, Healthfirst investigate existing compliance procedures to identify areas where improvements could be made to ensure that these diagnosis codes comply with federal requirements. Healthfirst did not object to the OIG’s findings, but it disagreed with all recommendations, as it claimed the OIG lacked the authority to use extrapolation to recommend a repayment, claimed the audit methodology did not account for a payment principle known as “actuarial equivalence,” and disagreed that it needed to perform audits of high-risk diagnoses or enhance its compliance program. After reviewing Healthfirst’s comments, the OIG maintained its findings and recommendations.


Billing Monoclonal Antibodies and COVID-19 Vaccines for Medicare Advantage Beneficiaries

On January 7, CMS updated its Monoclonal Antibody COVID-19 Infusion and Medicare Billing for COVID-19 Vaccine Shot Administration webpages to note that, effective for dates of service on or after January 1, 2022, any claims for monoclonal antibody infusions or COVID-19 vaccine administration for Medicare Advantage beneficiaries should be billed to the Medicare Advantage plan. Original Medicare won’t pay these claims beginning January 2022.


New HCPCS Code for Remdesivir Antiviral Medication

On January 7, CMS published a Special Edition MLN Connects regarding the creation of a new HCPCS code (J0428) for VEKLURY™ (remdesivir) when administered in an outpatient setting. This code is effective for dates of service on or after December 23, 2021.