This week in Medicare updates—12/4/2019
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for CY 2020 - Recurring File Update
On November 20, CMS published Medicare Claims Processing Transmittal 4403 regarding updates to the PPS base payment rate and the Geographic Adjustment Factors for the FQHC Pricer. The FQHC market basket update for CY 2020 is 2.2%, and the 2020 base payment rate is $173.50.
On November 25, CMS published MLN Matters 11500 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Overview of the Patient-Driven Groupings Model (PDGM)
On November 22, CMS published Special Edition MLN Matters 19027 regarding implementation of the PDGM and its impact on physicians ordering home health services. The article reviews eligibility criteria for home health services, the definition of a homebound patient, Medicare coverage for home health services, diagnosis reporting under PDGM, 30-day periods of care, and more. It also contains a variety of helpful tables and infographics to help providers understand compliance and documentation requirements for PDGM.
Effective date: January 1, 2020
Implementation date: January 1, 2020
Payments and Payment Adjustments under the Patient-Driven Groupings Model (PDGM)
On November 22, CMS published Special Edition MLN Matters 19028 regarding payment considerations under the PDGM. It contains similar tables and infographics as SE19027 and provides additional information on case-mix weights and payment calculations and adjustments.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Additional Guidance on Private Contracting/Opting-out of Medicare and Entering Opt-out Affidavit Records in the PECOS
On November 22, CMS published Medicare Program Integrity Transmittal 926 regarding instructions to MACs on how to process physician and eligible non-physician practitioners’ affidavits to opt out of Medicare. It also provides instructions on how to appropriately create and maintain opt out affidavit records in the PECOS.
Effective date: December 24, 2019
Implementation date: December 24, 2019
Provider Compliance Tips for Home Health Services (Part A Non-DRG)
On November 25, CMS published an MLN Fact Sheet regarding compliance issues related to home health services. In 2018, improper home health payments accounted for 9.8% of the overall Medicare fee-for-service improper payment rate. The projected total of these improper payments was $3.2 billion. In an attempt to help mitigate improper home health payments, CMS provided information in this fact sheet on documentation requirements, considerations for physician certification/re-certification, the criteria for considering a beneficiary’s status as “confined to the home,” and required elements in the plan of care.
Medicare Disproportionate Share Hospital
On November 25, CMS published an MLN Fact Sheet regarding a variety of topics related to Disproportionate Share Hospitals (DSH). It includes information on qualification criteria for DSH adjustments, special exceptions, legislative considerations impacting DSH payments, adjustment formulas, and more. The fact sheet also includes a comprehensive list of links to additional information relevant to DSHs.
Application from Accreditation Commission for Health Care for Initial CMS Approval of its Home Infusion Therapy Accreditation Program
On November 25, CMS published a Notice with Request for Comment in the Federal Register to announce it has received an application from the Accreditation Commission for Health Care for initial recognition as an accreditation organization for suppliers of home infusion therapy services. Comments on the application are due by December 26, 2019.
Continued Approval of the Accreditation Commission for Health Care Accreditation Program
On November 25, CMS published a Notice in the Federal Register to announce it has approved the Accreditation Commission for Health Care’s request for continued recognition as an accrediting organization for hospices.
Dates: This final notice is effective November 27, 2019, through November 27, 2025.
Statement of Organization, Functions, and Delegations of Authority
On November 25, CMS published a Notice in the Federal Register regarding restructuring for certain departments within CMS. The notice announces the establishment of a new Office of Program Operations and Local Engagement (OPOLE) as well as the abolishment of the Consortium for Medicare Health Plan Operations (CMHPO), the Consortium for Financial Management and Fee for Service Operations (CFMFFSO), and the Consortium for Quality Improvement and Survey and Certification Operations (CQISCO). Several other departments were also restructured to align audit management activities, change the reporting relationship of the Emergency Preparedness and Response Operations, and modernize CMS’s approach to public and internal communications.
Updated Civil Monetary Penalties and Affirmative Exclusions
On November 26, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following:
- On October 17, Julio C. Gonzalez, M.D., of Falls Church, Virginia, reached a $29,378.26 settlement with the OIG to resolve allegations that Gonzalez submitted claims to Medicare for nerve conduction studies, which are screening exams and are not covered by Medicare.
- On November 1, Eastern Area Specialty Transport, Inc. (EAST), and David Haines, of Leesbury, Ohio, agreed to a five-year exclusion following an OIG investigation which determined EAST presented Part B claims for ambulance transport to and from SNFs when the transport was already covered by the SNF consolidated billing payment under Part A.
- On November 4, Hospital Authority of Valdosta and Lowndes County, d/b/a South Georgia Medical Center, of Valdosta, Georgia, reached a $40,000 settlement with the OIG to resolve allegations that SGMC violated EMTALA by failing to provide examination and treatment by an on-call urologist, who refused to come to the ED to examine or treat the patient and instead had the patient unnecessarily transferred to a different hospital for treatment.
Hospitals Received Millions in Excessive Outlier Payments Because CMS Limits the Reconciliation Process
On November 27, the OIG published a Review determining whether CMS paid hospitals more for Medicare outlier payments than the hospitals would have been paid if the outlier payments had been reconciled. CMS requires MACs to reconcile outlier payments if the cost report has an actual cost-to-charge ratio (CCR) of plus or minus 10% from the CCR applied during the payment period and if the outlier payments in that cost reporting period exceed $500,000. The OIG recalculated outlier payments for 60 hospitals who received $3.5 billion in outlier payments from 2011-2014. The OIG found that, for the 60 hospitals, CMS paid $502 million more in outlier payments than it would have if the payments had been reconciled, but CMS did not detect this because the cost reports for these hospitals didn’t meet the reconciliation criteria. These hospitals had increased their charges at a rate higher than the rate of cost increases, which would only result in a small percentage point change in the CCR. Of the cost reports for these hospitals, 92% had changes of less than 5%, far below CMS’s reconciliation threshold of 10%.
The OIG recommends CMS require reconciliation of all hospital cost reports with outlier payments during a cost-reporting period. CMS concurred with the recommendation and stated it is evaluating the current outlier reconciliation criteria and will consider whether to propose any modifications to outlier reconciliation in future rule-making.
November Patients Over Paperwork Newsletter
On November 27, CMS published the November edition of the Patients Over Paperwork newsletter. This issue covers the rural perspective on burden reduction, discussion of simplified documentation for immunosuppressive drugs and home health recertification, RAC audit updates, and more.
Automation of Part B Underpayment Processing of Recovery Audit Contractor (RAC) Adjustments
On November 27, CMS published One-Time Notification Transmittal 2403, which rescinds and replaces Transmittal 2329, dated August 2, 2019, to remove business requirements 11285.4.1 and 11285.4.2. The original transmittal was issued regarding automation of a process that will allow for RAC-identified Part B underpayments to process without manual intervention.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Implementation to Adopt the Document Codes in the Post-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System
On November 27, CMS published One-Time Notification Transmittal 2402 regarding implementation of changes required to allow review contractors to support sending ADR letters for both medical and non-medical review electronically as eMDRs beginning in January 2020. This transmittal is part of a multi-step series, and it focuses on populating appropriate/Standardized Document Codes while generating and sending certain package information to esMD.
Effective date: July 1, 2020
Implementation date: April 6, 2020 - Analysis, Design, Coding; July 6, 2020 - Testing and Implementation
Summary of Policies in CY 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
On November 27, CMS published Medicare Claims Processing Transmittal 4468 regarding implementation of policies from the 2020 MPFS final rule and to announce the telehealth originating facility fee payment amount, which will be 80% of the lesser of the actual charge or $26.65. Some of the policies described in the transmittal include allowing a broader list of providers to review and verify instead of re-documenting information in the medical record, creating new codes for chronic care management services, implementing the opioid treatment program benefit, and more.
Effective date: January 1, 2020
Implementation date: January 6, 2020