This week in Medicare updates—2/23/2022
Advisory Opinion No. 22-03
On February 14, the OIG published an Advisory Opinion regarding an arrangement in which a company who owns and operates home health agencies would pay the tuition costs of nurse aide certification programs for new employees who have been hired to work as certified nurse aides (CNA) but who have not yet passed the requisite state certification exam. While the arrangement would be offered regardless of financial need and would be advertised as a benefit available to all new employees, the company said it anticipates that the vast majority of individuals who would participate would be parents or relatives of Medicaid-eligible, medically fragile children. The company also anticipates that these parents or relatives would refer such children to one of the company’s HHAs. The company is requesting an opinion as to whether this arrangement would be grounds for the imposition of sanctions under civil monetary penalties related to the anti-kickback statute and prohibition on beneficiary inducements.
The OIG said that the arrangement would not generate remuneration under the federal anti-kickback statute or beneficiary inducements CMPs, and therefore the OIG would not impose administrative sanctions on the requestors.
COVID-19 FAQs on Medicare Fee-for-Service Billing
On February 16, CMS updated its FAQs for Medicare providers regarding COVID-19 billing. The update was published regarding how CMS will pay for remdesivir when it is administered in the outpatient setting.
Comment Request: Complaints Submission Process Under the No Surprises Act; End Stage Renal Disease Application and Survey and Certification Report
On February 16, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Complaints Submission Process Under the No Surprises Act
- End Stage Renal Disease Application and Survey and Certification Report
Comments are due by April 18, 2022.
Updated OIG Work Plan
On February 16, the OIG updated its Work Plan with the following new items:
- Ensuring Dual-Eligible Beneficiaries' Access to Drugs Under Part D: Mandatory Review
- Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2020 Average Sales Prices
- Biosimilar Trends in Medicare Part B
- Medicare Beneficiaries Receiving Buprenorphine for the Treatment of Opioid Use Disorder
- Nursing Home Capabilities and Collaboration to Ensure Resident Care During Emergencies
Medicare Payments of $6.6 Billion to Non-hospice Providers Over 10 Years for Items and Services Provided to Hospice Beneficiaries Suggest the Need for Increased Oversight
On February 16, the OIG published a Data Brief regarding Medicare payments to non-hospice providers for items and services provided to hospice beneficiaries. The data was compiled for CYs 2010-2019 and looked at non-hospice payments for both Part A and Part B items and services. The OIG did not assess whether the payments were for items and services that treated conditions unrelated to the beneficiary’s terminal illness and related conditions. The OIG found that CMS paid $6.6 billion to non-hospice providers for hospice beneficiaries during this time period, and the majority of those payments were for Part B items and services. Non-hospice payments for Part A services decreased by 45% over the 10 years of the audit period while payments for Part B services increased by 38% during the audit period. The OIG also found that there was an 87% increase in hospice payments to for-profit hospices over the 10 years, and there was a 78% increase in the number of for-profit hospice providers, far outpacing the nonprofit hospices.
CLIA Consumer Complaints FAQ and Consumer Infographic on Temporary Laboratory Testing Sites
On February 17, CMS published an FAQ and an Infographic regarding CLIA consumer complaints and what to watch for that may indicate a potentially fraudulent laboratory site. Both resources appear to be attempts from CMS to help consumers identify healthcare fraud.
Medicare Advantage Compliance Audit of Diagnosis Codes that Tufts Health Plan Submitted to CMS
On February 17, the OIG published a Review of whether select diagnosis codes that Tufts Health Plan, a Medicare Advantage organization, submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by selecting 212 enrollee years high-risk diagnosis codes for which Tufts received higher payments for 2015-2016. The OIG found that 154 of the 212 sampled enrollee years had diagnosis codes that were not supported in the medical records. The OIG estimated that Tufts received at least $3.7 million in net overpayments due to these errors.
The OIG recommended that Tufts refund the federal government for the $3.7 million in net overpayments, identify and return any similar overpayments, and improve its existing compliance procedures to identify areas where improvements can be made regarding diagnosis codes at high risk for being miscoded. Tufts did not agree with the OIG’s findings and stated that the report reflected misunderstandings of legal and regulatory requirements underlying the Medicare Advantage program. It also noted that it had already submitted corrections to CMS on behalf of five enrollee years with errors in coding, and the OIG subsequently revised its findings for those years. The OIG maintains that its other findings and recommendations were valid.
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2022 Update
On February 17, CMS published Medicare Claims Processing Transmittal 11268 regarding the April update to the MPFS payment files. Updates include seven new HCPCS codes, changes to procedure status and payment policy indicators, and more.
CMS published MLN Matters 12623 on the same date to accompany the transmittal.
Effective date: April 1, 2022
Implementation date: April 4, 2022
Updated Corporate Integrity Agreement Documents
On February 18, the OIG published information on a new Corporate Integrity Agreement with the following entity:
FDA Issues EUA for Bebtelovimab for Treatment of Mild-to-Moderate COVID-19
On February 18, CMS updated its COVID-19 Monoclonal Antibodies webpage to announce that the FDA issued an EUA, effective February 11, 2022, for bebtelovimab, a new monoclonal antibody treatment for COVID-19. Providers should report this drug with product code Q0222 and administration code M0222 (Intravenous injection, bebtelovimab, includes injection and post administration monitoring) or M0223 (Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 PHE).
Omnibus CR Covering Removal of Two NCDs; Updates to Medical Nutrition Therapy Policy; and Updates to Pulmonary, Cardiac, and Intensive Cardiac Rehabilitation Conditions of Coverage
On February 18, CMS published Medicare Benefit Policy Transmittal 11272, Medicare Claims Processing Transmittal 11272, and Medicare National Coverage Determinations Transmittal 11272 regarding a variety of updates to the manuals based on policies finalized in the 2022 Medicare Physician Fee Schedule Final Rule. This includes the removal of NCDs 180.2 (Enteral/Parenteral Nutritional Therapy) and 220.6 (PET Scans) as well as updated information on medical nutrition therapy policies to align with policies established in the rule. It also includes updates to pulmonary, cardiac, and intensive cardiac rehabilitation policies.
Effective date: January 1, 2022 - By statute
Implementation date: July 5, 2022