This week in Medicare updates—1/23/2019
Provider Compliance Tips for Tracheostomy Supplies
On January 14, CMS published a Fact Sheet regarding ways to prevent denials and improper payments for tracheostomy supplies. The improper payment rate for tracheostomy supplies during the 2018 reporting period was 61.5%, and CMS published the fact sheet to remind providers and suppliers of documentation requirements and order requirements in order to comply with Medicare regulations.
Provider Compliance Tips for Ventilators
On January 14, CMS published a Fact Sheet regarding ways to prevent denials and improper payments for ventilators. The improper payment rate for ventilators during the 2018 reporting period was 29.6%, and 70.3% of these improper payments were due to insufficient documentation. The fact sheet reviews coverage, order, and documentation requirements in order to help providers and suppliers comply with Medicare regulations.
Provider Compliance Tips for Canes and Crutches
On January 14, CMS published a Fact Sheet regarding ways to prevent denials and improper payments for canes and crutches. The improper payment rate for canes and crutches during the 2018 reporting period was 56.3%, and 77.9% of those improper payments were due to insufficient documentation. The fact sheet reviews coverage, order, and documentation requirements for these supplies in order to help providers and suppliers comply with Medicare regulations.
National Coverage Analysis Tracking Sheet for Acupuncture for Chronic Low Back Pain
On January 15, CMS published a Tracking Sheet to initiate a national coverage analysis (NCA) which will review whether acupuncture for chronic low back pain is reasonable and necessary under the Medicare program. CMS is pursuing this topic in part as a way to prevent opioid use disorder by providing more evidence-based, non-pharmacologic treatment options for chronic pain. The posted tracking sheet begins an initial 30-day public comment period, which will end on February 14, 2019.
Updated OIG Work Plan
On January 16, the OIG updated its Work Plan with the following new items:
- Medicare Payments for Clinical Diagnostic Laboratory Tests in 2018: Year 1 of New Payment Rates
- Follow-up Review on Inpatient Claims Subject to the Post-Acute Care Transfer Policy
- Medicare Outpatient Outlier Payments for Claims With Credits for Replaced Medical Devices
- Duplicate Payments for Home Health Services Covered Under Medicare and Medicaid
CMS Finalizes New Medicare Card Distribution Ahead of Deadline
On January 16, CMS published a Press Release to announce it completed distribution of new Medicare cards to beneficiaries three months ahead of the April 2019 deadline. CMS reported that more than half of fee-for-service claims submitted for the week ending January 11 were submitted with the new MBI numbers, which signals a smooth transition to use of the new cards.
Proof of Delivery Documentation Requirements
On January 17, CMS published Special Edition MLN Matters 19003 regarding simplified requirements for proof of delivery and documentation of durable medical equipment as clarified in CR 10324. The article reviews requirements for supplier proof of delivery documentation and equipment examinations, methods of initial delivery and signature requirements, special situations unique to newly eligible beneficiaries, and more.
Effective date: November 20, 2017
Implementation date: November 20, 2017
CY 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
On January 17, CMS published Medicare Claims Processing Transmittal 4208, which rescinds and replaces Transmittal 4182, dated December 14, 2018, to remove code 0008U from the list of revised codes effective January 1, 2019. The original transmittal was issued regarding instructions for the CY 2019 clinical lab fee schedule, mapping for new codes for clinical lab tests, and updates for lab costs subject to the reasonable charge payment.
On December 17, CMS published MLN Matters 11076 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On January 17, CMS published Medicare Claims Processing Transmittal 4204, which rescinds and replaces Transmittal 4186, dated December 31, 2018, to fix the links under policy section I.B.11.d. The original transmittal was issued regarding the recurring updates to various payment policies implemented in the January 2019 OPPS update.
Effective date: January 1, 2019
Implementation date: January 7, 2019
CY 2019 Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
On January 18, CMS published Medicare Claims Processing Transmittal 4209, which rescinds and replaces Transmittal 4181, dated December 14, 2018, to delete codes A6460 and A6461 from BR #11064.10 and remove category code 60 for these codes in BR #11064.7. The original transmittal was issued regarding instructions for the 2019 annual update to the DMEPOS fee schedule.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Updated Civil Monetary Penalties and Affirmative Exclusions
On January 18, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:
- On December 21, 2018, Tulsa Pain Consultants, Inc., Martin Martucci, M.D., and Andreas Revelis, M.D., of Tulsa, Oklahoma, reached a $98,942.50 settlement with the OIG to resolve allegations of receiving improper remuneration from Millennium Health, LLC, in the form of point of care test cups which resulted in prohibited referrals
- On January 4, Baptist Village of Owasso, of Owasso, Oklahoma, reached a $96,020.92 settlement agreement with the OIG to resolve allegations that it employed an individual who was excluded from participating in any federal health care programs
Although CMS Has Made Progress, It Did Not Always Resolve Audit Recommendations in Accordance with Federal Requirements
On January 18, the OIG published a Review of whether CMS has made progress in the timely resolution of audit recommendations since the previous review from 10 years ago. This review, which examined an audit period from FYs 2015 and 2016, determined that CMS did not resolve 32.9% of the audit recommendations within a six-month resolution period. This was a drastic improvement from the previous audit in FYs 2006 and 2007, when CMS did not resolve 81.2% of reviews within the six-month resolution period. The OIG recommends that CMS continue to follow policies and procedures related to the audit resolution process and enhance them where possible. The OIG also recommends CMS resolve a remaining 140 outstanding audit recommendations due as of September 30, 2016. CMS concurred with the recommendations and stated that it has already resolved 97 of those 140 open recommendations.
CMS Announces New Model to Lower Drug Prices in Medicare Part D and Transformative Updates to Existing Model for Medicare Advantage
On January 18, CMS published a Press Release regarding two new innovative payment and service delivery models for Medicare Advantage and Part D aimed toward improving quality and lowering cost. The Part D Payment Modernization model will create new incentives for plans, patients, and providers to choose drugs with lower list prices; introduce two-sided risk payment incentives for plan sponsors with their enrollees and CMS; and provide program flexibilities including rewards and incentives to ensure Medicare beneficiaries are able to maintain affordable access to needed prescription drugs. The Medicare Advantage model updates the Medicare Advantage Value-Based Insurance Design model to include new interventions involving cost-sharing or additional benefits based on condition or socioeconomic status, additional rewards and incentives, increased utilization of telehealth networks, and wellness and health care planning requirements.
Both models are voluntary and are effective for plan year 2020. CMS published separate fact sheets on the Part D model and Medicare Advantage model on the same date.