This week in Medicare updates—11/25/2020

November 25, 2020
Medicare Insider

2020 Estimated Improper Payment Rates for CMS Programs

On November 16, CMS published a Press Release and Fact Sheet regarding data on 2020 estimated improper payments as required by the Payment Integrity Information Act of 2019. The 2020 estimated improper payment rates for Medicare FFS (6.27%) and Medicare Part C (6.78%) decreased from the 2019 rates while the Part D improper payment rate (1.15%) increased from the 2019 rate (0.75%). CMS said the FFS rates likely decreased due to reductions in improper payments for home health and SNF claims, and it attributed the Part C reduction to Medicare Advantage organizations submitting a greater number of medical records that validated diagnoses. CMS did not identify a factor for the increase in the Part D improper payment rate.


Special Fraud Alert: Speaker Programs

On November 16, the OIG published a Fraud Alert regarding fraud and abuse risks associated with speaker programs by pharmaceutical and medical device companies. The fraud alert reminds health care professionals and companies hosting speaker programs that the government has pursued civil and criminal cases against companies and health care professionals due to certain types of speaker programs. These include: 

  • selecting high-prescribing health care professions and paying them lucrative deals to be speakers 
  • conditioning speaker remuneration on sales targets (such as a minimum number of prescriptions written)
  • holding speaker programs in a manner not conducive to an educational presentation
  • holding programs at high-end restaurants where expensive meals/alcohol were served
  • inviting health care professionals who had previously attended the same program or inviting the health care professionals’ friends, family, etc. when they did not have a legitimate business reason to attend the program

While the OIG said it recognized many of these programs are currently on hold during the pandemic, it reminds health care professionals that these risks still exist and could become more pronounced once in-person events or speaker program remuneration returns. 


Updated OIG Work Plan

On November 16, the OIG updated its Work Plan with the following new items:


Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP): Results for the Second Quarter of 2020

On November 17, the OIG published a Report regarding drugs for which the ASP exceeds the AMP by 5% or more for two consecutive quarters or three of the previous four quarters. When this happens, CMS substitutes 103% of the AMP for the ASP-based reimbursement. In the second quarter of 2020, seven drug codes met this price substitution criteria. The OIG will provide these results to CMS for review.


2020 Top Management & Performance Challenges Facing HHS

On November 17, the OIG published a List of the top management and performance challenges facing HHS in 2020. Not surprisingly, the top challenge in 2020 was safeguarding public health. This was followed by ensuring the financial integrity of HHS programs; delivering value, quality, and improved outcomes in Medicare and Medicaid; protecting the health and safety of HHS beneficiaries; harnessing data to improve health and well-being of individuals; and improving collaboration to better serve our nation.


Monoclonal Antibody COVID-19 Infusion Webpage

On November 17, CMS updated a Webpage regarding information on billing, coding, and payment for COVID-19 monoclonal antibody treatments. The webpage also contains a link to a page listing all current CPT codes and payment allowances for both COVID-19 vaccines and monoclonal antibody treatment payable under Part B. The page contains various links to additional guidance on these treatments and vaccines.


Nursing Home COVID-19 Training Data

On November 17, CMS published a Press Release regarding the CMS Targeted COVID-19 Training for Frontline Nursing Home Staff & Management. CMS said approximately 12.5% of the nation’s nursing home staff (125,506 individuals from over 7,000 nursing homes nationwide) have completed the training, and 1,092 nursing homes had 50% or more of their staff complete the training. CMS is urging every nursing home to take advantage of this training as part of the effort to combat COVID-19. It also published a List of the nursing homes who had 50% or more of their staff complete the training.  


Hospitals Did Not Comply With Medicare Requirements for Reporting Cardiac Device Credits

On November 18, the OIG published a Review of whether hospitals complied with Medicare requirements for reporting manufacturer credits associated with recalled or prematurely failed cardiac devices. The OIG found that, of the 6,558 claims reviewed, nearly half (3,233) likely did not comply with Medicare requirements for reporting manufacturer credits for recalled or prematurely failed cardiac medical devices. The OIG also found that, of the 911 hospitals responsible for these noncompliant claims, none reported what the OIG deemed to be the correct condition and value codes for the reportable credits associated with the claims. The OIG said that Medicare contractors paid $33 million in potential overpayments for these claims and the contractors do not have a postpayment review process that would ensure hospitals correctly reported manufacturer credits for cardiac medical devices.

The OIG recommends that CMS instruct the MACs recover the overpayments within the reopening period; notify hospitals so they can identify, report, and return any similar overpayments; require hospitals to use condition codes 49 and 50 on claims; instruct MACs to implement a postpayment review process; obtain device credit listings from manufacturers to determine whether providers reported credits as required; direct MACs to determine whether hospitals are engaging in a pattern of incorrect billing after the audit period and take appropriate actions if so; and consider eliminating current Medicare requirements for reporting device credits by reducing payments for cardiac device replacement procedures. For reasons explained within the report, CMS did not concur with recommendations to require hospitals to use condition codes 49 or 50 on claims, instruct MACs to implement a postpayment review process, obtain device credit listings from manufacturers, or direct MACs to identify hospitals with a pattern of these billing issues.


Medicare Accelerated and Advance Payments Program COVID-19 PHE Payment Data

On November 18, CMS updated a Document containing over 1500 pages of data on the accelerated and advanced payments provided during the COVID-19 PHE through November 5. Payments so far have totaled over $107 billion, most of which (92.07%) was made via accelerated payments. The payments come from the Federal Hospital Insurance Trust Fund (65%) and the Federal Supplementary Insurance Trust Fund (35%). The document contains a summary of payments made by provider and supplier type and a listing of all providers and suppliers by name who received payments as well as the amount they received through the program.


How Facilities Can Safely Recognize Holidays

On November 18, CMS published an Alert to nursing homes, residents, and resident family members and/or representatives regarding recommendations for celebrating holidays safely during the COVID-19 pandemic. CMS recommends that nursing homes educate families and residents on the risks of having a resident leave the facility for a holiday and ways to reduce those risks. The alert also includes guidance on actions nursing homes should take upon a resident’s return to the facility after the holidays.

CMS published a Press Release about the alert on the same date.


Medicare Hospital Provider Compliance Audit: Edward W. Sparrow Hospital

On November 19, the OIG published a Review of whether Edward W. Sparrow Hospital complied with Medicare requirements for billing inpatient and outpatient services for certain claims that were potentially at risk for billing errors. The OIG determined that Sparrow complied with Medicare requirements for 91 of the 100 claims reviewed and only found errors with five inpatient claims (insufficient documentation in the medical record to support the necessity for inpatient hospital services) and four outpatient claims (incorrectly coded ER E/M services). The OIG estimated that this resulted in overpayments of at least $550,917 for the audit period. 

The OIG recommends Sparrow exercise reasonable diligence to identify, report, and return overpayments in accordance with the 60-day rule. The hospital disagreed with the OIG’s findings and will appeal. The OIG maintained its original findings were correct but removed one recommendation because the 4-year reopening period has ended.


Implementation of Two New NUBC Condition Codes

On November 20, CMS published One-Time Notification Transmittal 10470 regarding the creation of two new NUBC condition codes. These include condition code 90 (service provided as part of an Expanded Access approval) for inpatient and outpatient claims with reported Expanded Access services, and condition code 91 (service provided as part of an Emergency Use Authorization) for inpatient and outpatient claims that have reported EUA services. 

Effective date: February 1, 2021 - for claims received on or after 2/1/2021

Implementation date: February 22, 2021 (MACs); January 4, 2021 (FISS - for documentation updates, using April hours)


Update to Medicare Deductible, Coinsurance, and Premium Rates for CY 2021

On November 20, CMS published General Information, Eligibility, and Entitlement Transmittal 10469 regarding an instruction to the contractors to update the claims processing system with the new CY 2021 Medicare rates. 

Effective date: January 1, 2021

Implementation date: January 4, 2021


April 2021 HCPCS Quarterly Update Reminder

On November 20, CMS published One-Time Notification Transmittal 10475 regarding the quarterly update of the complete HCPCS file. The April 2021 update will be available for download via the CMS mainframe in March 2021. 

Effective date: April 1, 2021

Implementation date: April 5, 2021