This week in Medicare updates—2/9/2022
Health Care Facility Administrator COVID-19 Vaccine Letter
On February 1, CMS published a Letter from CMS Administrator Chiquita Brooks-LaSure to health care facility administrators to remind them that the federal government is requiring all healthcare staff to be vaccinated against COVID-19. Legal challenges to this requirement were defeated in the Supreme Court and a related case in Texas was dismissed, thus making this vaccination requirement effective nationwide. The letter links to guidance CMS released on compliance with the vaccination requirement.
Comment Request: Standards Related to Reinsurance, Risk Corridors, Risk Adjustment, and Payment Appeals
On February 1, CMS published a Comment Request in the Federal Register regarding an information collection titled “Standards Related to Reinsurance, Risk Corridors, Risk Adjustment, and Payment Appeals.”
Comments are due by April 4, 2022.
Nursing Home Visitation FAQs
On February 2, CMS updated an FAQ regarding nursing home visitation guidance during the COVID-19 PHE. Updates include information about improving air quality and air flow, whether states can require testing as a condition for visitation, funding for environmental changes, and more.
Updated Corporate Integrity Agreement Documents
On February 2, the OIG published information on a new Corporate Integrity Agreement with the following entity:
FDA Approves Moderna COVID-19 Vaccine
On February 2, CMS updated its COVID-19 Toolkit to note that the FDA approved the Moderna COVID-19 vaccine, which will be marketed as SPIKEVAX, for use in patients 18 years and older. CMS included a link to the FDA’s webpage on the Moderna vaccine.
CMS also updated its COVID-19 Vaccine Shot Payment webpage to change the layout of a table COVID-19 vaccine payment rates, although the information remains the same.
2023 Medicare Advantage and Part D Advance Notice
On February 2, CMS published the 2023 Medicare Advantage and Part D Advance Notice regarding Medicare Advantage capitation rates and Parts C and D payment policies for CY 2023. CMS will continue to calculate 100% of the risk score using the 2020 CMS-HCC model, but it is soliciting comments on whether enhancements can be made to the CMS-HCC risk adjustment model to address social determinants of health and possible impacts on beneficiary health status. CMS is proposing to apply a 5.9% coding pattern adjustment for CY 2023, which is the minimum adjustment for coding pattern differences required by statute. CMS is also proposing to use 2016-2020 fee-for-service risk scores to calculate the normalization factor for 2023 due to the possibility of skewed data from 2021 due to the COVID-19 pandemic.
CMS published a Fact Sheet and Press Release on the Advance Notice on the same date. Comments on proposals are due by March 4, 2022. The final rate announcement will be published no later than April 4, 2022.
Biden-Harris Administration Will Cover Free Over-the-Counter COVID-19 Tests Through Medicare
On February 3, CMS published a Press Release to announce that Medicare and Medicare Advantage beneficiaries will be able to get up to eight FDA-approved over-the-counter COVID-19 tests for free each month. CMS will pay for this by paying eligible pharmacies and participating entities directly for the tests in order to enable beneficiaries to receive tests for free.
CMS published an FAQ on the initiative on the same date.
FY 2022 April Update to ICD-10-CM Guidelines
On February 3, the CDC posted an Update to the FY 2022 ICD-10-CM Coding Guidelines to add guidance on when to code Z28.310 (Unvaccinated for COVID-19) and Z28.311 (Partially vaccinated for COVID-19), as these codes will be added to the code set in the April 1 update.
Comment Request: IRF-PAI for the Collection of Data Pertaining to the Inpatient Rehabilitation Facility Prospective Payment System and Quality Reporting Program
On February 3, CMS published a Comment Request in the Federal Register regarding an information collection titled, “IRF-PAI for the Collection of Data Pertaining to the Inpatient Rehabilitation Facility Prospective Payment System and Quality Reporting Program.”
Comments are due by April 4, 2022.
Updated Civil Monetary Penalties and Affirmative Exclusions
On February 4, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including:
- On January 10, Auspicious Laboratories, Inc., of Houston, TX, reached a $112,359.90 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for specimen validity testing in conjunction with urine drug testing when specimen validity testing was a non-covered service.
Medicare Advantage Compliance Audit of Diagnosis Codes that SCAN Health Plan Submitted to CMS
On February 4, the OIG published a Review of whether select diagnosis codes that SCAN 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 200 enrollees with at least one diagnosis code that mapped to an HCC for 2015 and looking at the 1,577 HCCs associated with those enrollees to see whether the medical records supported the use of those diagnosis codes. The OIG found that 164 of the 1,577 sampled HCCs were not validated by the medical records. Risk scores therefore should have been based on a lower number of HCCs, and the OIG estimated that SCAN received at least $54.3 million in net overpayments due to these incorrect HCCs and their effect on risk scores.
The OIG recommended that SCAN refund the federal government for the $54.3 million in net overpayments and improve its policies and procedures to prevent, detect, and correct noncompliance with federal requirements for diagnosis codes that are used to calculate risk-adjusted payments. SCAN disagreed with the OIG’s findings and stated that the medical reviewer erred in determinations by not validating certain HCCs and used flawed methods to identify samples of enrollees for audit and for extrapolation. After reviewing SCAN’s comments, the OIG revised its determination for the number of non-validated HCCs, reduced the estimated overpayments down from $66.9 million to $54.3 million, and revised the wording of one of its recommendations.
Claim Status Category and Claim Status Codes Update
On February 4, CMS published Medicare Claims Processing Transmittal 11251 regarding the updates to the Claim Status and Claim Status Category Codes used for the ASC X12 276/277 Health Care Claim Status Request and Response and the ASC X12 277 Health Care Claim Acknowledgment transactions.
Effective date: April 1, 2022
Implementation date: April 4, 2022
Nursing and Allied Health Medicare Advantage Payment - Revision to CY 2018
On February 4, CMS published One-Time Notification Transmittal 11248 regarding a correction to the CY 2018 percent reduction to direct GME MA payments to change it from 7% to 4.12%.
Effective date: March 7, 2022
Implementation date: August 8, 2022