This week in Medicare updates—1/9/2019
Clinical Laboratory Improvement Amendments of 1988 (CLIA) Fees
On December 31, CMS published a Notice with Comment Period in the Federal Register to announce the increase of certain fees established under CLIA. CMS is seeking public comments on the fee increases listed in the notice. Comments are due no later than 5 p.m. on March 1, 2019.
January 2019 Update of the Ambulatory Surgical Center (ASC) Payment System
On December 31, CMS published Medicare Claims Processing Transmittal 4191 regarding changes to and billing instructions for various ASC payment policies implemented in the January 2019 ASC payment system update. The transmittal also includes new HCPCS codes, including new separately payable codes for cardiac catheterization procedures.
CMS published MLN Matters 11108 on the same date to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Home Health Rural Add-On Payments Based on County of Residence
On December 31, CMS published Medicare Claims Processing Transmittal 4190, which rescinds and replaces Transmittal 4106, dated August 3, 2018, to correct the FIPS code link located under Section A of the Support Information. The original transmittal was issued regarding county-based rural add-on payments for home health services.
CMS revised MLN Matters 10782 on the same date to accompany the revised transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Updates to Immunosuppressive Guidance
On December 31, CMS published Medicare Claims Processing Transmittal 4189 regarding updates to the manual related to delivery of immunosuppressive drugs to an alternate address for beneficiaries who do not return home immediately after a procedure.
CMS published MLN Matters 11072 on the same date to accompany the transmittal.
Effective date: April 3, 2019
Implementation date: April 3, 2019
Dialysis Services Provided by Atlantis Health Care Group of Puerto Rico, Inc., Did Not Comply With Medicare Requirements Intended to Ensure the Quality of Care Provided to Medicare Beneficiaries
On January 3, the OIG published a Review of whether Atlantis Health Care Group of Puerto Rico, Inc., complied with Medicare requirements when providing dialysis care. The OIG found that Atlantis improperly claimed reimbursement for dialysis services for all 100 sample beneficiary-months in the sample, as claims for reimbursement for these services lacked adequate support for beneficiaries’ medical information, had plans of care or comprehensive assessments that did not comply with Medicare requirements, and had physicians’ orders that did not meet Medicare requirements. The OIG estimated that Atlantis received at least $403,000 in unallowable Medicare payments for dialysis services that did not comply with Medicare requirements. The OIG recommends Atlantis refund the Medicare program for that $403,000 amount and made a series of recommendations to strengthen Atlantis’ policies and procedures for ensuring dialysis services comply with Medicare requirements. Atlantis concurred with the OIG’s findings and recommendations.
Pacific Medical, Inc., Received Some Unallowable Medicare Payments for Orthotic Braces
On January 3, the OIG published a Review of whether Pacific Medical, Inc., complied with Medicare requirements when billing for selected orthotic braces. The OIG found that Pacific did not comply with Medicare requirements on 11 of the 100 sampled claims, as these claims either did not meet medical necessity requirements or lacked medical records completely. According to the OIG, Pacific Medical did not always obtain sufficient information from beneficiaries’ medical records to assure itself that claims for orthotic braces met Medicare requirements. The OIG recommends Pacific refund the estimated $247,493 in overpayments it received to the durable medical equipment MACs, identify and return any additional similar overpayments, and obtain as much information from beneficiary medical records as necessary to assure itself the claims for orthotic braces meet Medicare requirements.
Pacific did not concur with the OIG’s first recommendation, in part because it said as an accredited supplier, it follows the direction of referring licensed physicians in providing specific DMEPOS and it believes it should receive reimbursement for at least the least costly alternative to a delivered product when there is documentation of an order and delivery. The OIG said the supplier is liable for costs for an orthotic brace that does not meet medical necessity requirements as stipulated in Chapter 5 of the Medicare Program Integrity Manual.
Updates to the Appeals Prioritization Process
On January 4, CMS published Medicare Program Integrity Transmittal 853 regarding updates to Chapter 3 of the manual related to contractor participation in Administrative Law Judge hearings. The updates include changes related to the shift in oversight responsibility to Administrative Qualified Independent Contractors and the creation of a portal system for contractor selection of desired participant roles.
Effective date: February 5, 2019
Implementation date: February 5, 2019