This week in Medicare updates—12/12/2018

CMS Hospital Value-Based Purchasing Results for Fiscal Year 2019

On December 3, CMS published a Fact Sheet regarding the results of the Value-Based Purchasing Program for FY 2019. CMS estimates that the total amount available for value-based incentive payments in FY 2019 will be approximately $1.9 billion. The incentive payment adjustment factors for each participating hospital for FY 2019 have been posted in Table 16B of the FY 2019 IPPS Final Rule and Correction Notice Tables.

 

Extension of Prior Authorization for Repetitive Scheduled Non-Emergent Ambulance Transports

On December 4, CMS published a Notice in the Federal Register to announce a one-year extension of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport. The extension is applicable to the District of Columbia, Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia.

Dates: This extension begins on December 2, 2018 and ends on December 1, 2019.

 

Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of
Their Standard Charges via the Internet

On December 4, CMS released additional FAQs regarding the 2019 IPPS final rule requirement that hospitals post a list of their standard charges on the internet. The document covers topics such as the types of providers required to participate in this initiative, what format to use when posting these lists, and what will happen if a hospital does not comply with this policy.

 

Medicare Improperly Paid Suppliers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Provided to Beneficiaries During Inpatient Stays

On December 4, the OIG published a Review of whether Medicare properly paid suppliers for DMEPOS items provided to beneficiaries during inpatient stays. The OIG found that Medicare should not have paid suppliers for any of the $34 million for DMEPOS items provided during inpatient stays, and beneficiaries should not have been held responsible for $8.7 million in unnecessary deductibles and coinsurance paid to suppliers for these DMEPOS items. These overpayments were caused by inadequate system edits that failed to prevent or detect these overpayments. The OIG recommends CMS direct the contractors to recover the $34 million in identified improper payments, suggests that CMS recommend that suppliers refund beneficiaries the $8.7 million in deductibles and coinsurance that may have been incorrectly collected, and identify and recover any improper payments to suppliers after the audit period.

The OIG also recommends CMS take all necessary actions, including seeking legislative authority, to require suppliers to refund beneficiaries for incorrectly collected deductibles/coinsurance and to correct system edits to prevent or detect overpayments to suppliers for DMEPOS items provided during inpatient stays. CMS said it would consider whether to include the recommendation involving seeking legislative authority to require suppliers to refund beneficiaries in the agency’s recommended proposals for the President’s next budget.

 

Adverse Events in Long-Term Care Hospitals: National Incidence Among Medicare Beneficiaries

On December 4, the OIG published a Review of the frequency and nature of adverse events in long-term care hospitals (LTCH). The OIG found that 21% of Medicare patients in LTCHs experienced adverse events based on a sample from March 2014, and an additional 25% of patients experienced temporary harm events. The OIG estimates that over half of the adverse and temporary harm events were clearly or likely preventable. The OIG recommends that CMS and the Agency for Healthcare Research and Quality (AHRQ) should tailor ongoing efforts to improve patient safety to address the specific needs of LTCHs. It also recommends that AHRQ and CMS collaborate to create and disseminate a list of potential harm events in LTCHs.

 

CMS Strengthens Federal Support to Alaska Residents Affected By Earthquake

On December 6, CMS published a Press Release on actions it is taking to support Alaska residents affected by the recent earthquake north of Anchorage. These actions include waivers for skilled nursing facilities and assistance for hospitals and other healthcare facilities; special enrollment opportunities to allow for immediate access to healthcare; and steps to ensure dialysis patients can obtain services.

CMS published Special Edition MLN Matters 18027 on the same date to provide more detailed information on the federal assistance available for providers and suppliers impacted by the earthquake. For more information on CMS activities related to the earthquake, visit CMS’ emergency website.

 

CMS Office of the Actuary Releases 2017 National Health Expenditures

On December 6, CMS published a Press Release regarding a study on 2017 national health spending conducted by the Office of the Actuary at CMS. According to the report, overall national health spending grew at a rate of 3.9% in 2017, nearly 1% slower than growth in 2016. The three largest goods and services categories—hospital spending, physician and clinical services spending, and retail prescription drug spending—all grew at slower paces than in previous years. Medicare spending grew 4.2% in 2017 to $705.9 billion, similar to the pace of its growth in 2016, when spending grew by 4.3%.

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On December 6, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:

• On November 13, the OIG excluded Medicus Laboratories, LLC, of Dallas, Texas, for defaulting on payment obligations under a settlement agreement with the OIG wherein the OIG alleged Medicus submitted false or fraudulent claims to Medicare. Medicus’ exclusion will remain in effect until it resolves the default of its payment obligations and the OIG reinstates Medicus’ participation in federal health care programs.
• On November 19, Southern Connecticut Vascular Center, LLC, of Stratford, Connecticut, reached a $792,076.76 settlement agreement with the OIG to resolve allegations that SCVC submitted claims for HCPCS code 96965 for a procedure that was already included as a component of the duplex ultrasound reported by 93970 or 93971 for which SCVC submitted claims for the same beneficiary on the same dates of service. The OIG also alleged that the claims for HCPCS code 93965 were for a procedure that should not have been separately billed and was not medically necessary.
• On November 27, Michael L. Drerup, M.D., and the Alexandria Neurosurgical Clinic, of Alexandria, Louisiana, reached an $80,941.82 settlement agreement with the OIG to resolve allegations of submitting claims to Medicare for nerve conduction studies that are considered screening exams and are not covered by Medicare.

The list also includes two settlements from facilities who allegedly employed individuals they knew or should have known were excluded from participation in federal healthcare programs. Those facilities include:

• University of Chicago Medical Center, of Chicago, Illinois
• Spurwink Services, of Portland, Maine

 

Updated Provider Self-Disclosure Settlements

On December 6, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

• On November 1, McBride Clinic Orthopedic Hospital, LLC d/b/a McBride Orthopedic Hospital, of Oklahoma, agreed to pay $414,649.91 for improperly submitting claims to federal health care programs for professional services related to surgeries performed by two employee-physicians improperly appended by modifiers -51, -58, and/or -59; professional and facility fees related to post-surgical patient visits performed by an LPN without physician supervision; E/M services performed by an employee-physician during office visits improperly appended by modifier -25 and/or billed as split shared. The OIG alleged that when McBride became aware through educational audits of overpayments owed to Medicare, it failed to return those overpayments to Medicare.
• On November 19, Milton S. Hershey Medical Center, of Pennsylvania, agreed to pay $382,074.60 for allegedly providing outpatient radiology imaging services to federal health care program patients when its employed radiologists did not provide personal supervision of employed radiology assistants.

The list also includes two facilities who agreed to payments due to employing individuals these facilities knew or should have known were excluded from participation in federal health care programs. These facilities include:

• Odyssey HealthCare Operating A, LP d/b/a Kindred Hospice
• Fox Rehabilitation Services, P.C.

 

Correction: Changes to the Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedures

On December 6, CMS published a Correction in the Federal Register to correct technical and typographical errors in the Changes to Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedures proposed rule, dated October 2, 2018.

 

Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update

On December 7, CMS published Medicare Benefit Policy Transmittal 252 regarding revisions to the manual to include the payment policy for Care Management in RHCs and FQHCs as finalized in the CY 2019 Physician Fee Schedule final rule. The revisions to Chapter 13 of the manual also include some clarifications of existing policy.

Effective date: January 1, 2019

Implementation date: January 2, 2019