This week in Medicare updates—3/11/2020

March 11, 2020

Medicare Insider

CHI St. Vincent Infirmary: Audit of Outpatient Outlier Payments

On March 2, the OIG published a Review of whether CHI St. Vincent Infirmary properly billed claims with outpatient outlier payments. The OIG found that 103 of the 120 claims reviewed were not billed properly and contained a total of 173 billing errors, which the OIG said was due to St. Vincent having inadequate controls that would prevent errors related to overcharged time, charge errors, and coding errors. Some of these errors included overcharging hard coded charges by billing codes that did not follow St.Vincent’s pricing policy; overcharging for time in the OR, anesthesia, recovery room, and observation; failing to charge for services that were documented, charging inappropriately for recovery room with conscious sedation, and more. The claims in error had outliers totaling $581,136.

The OIG recommends St. Vincent amend the claims with errors to identify and return any improper outlier payments. It also recommends St. Vincent improve procedures and provide education to ensure claims billed to Medicare are accurate.

Comment Request: Notice of Denial of Medicare Prescription Drug Coverage; Collection of Diagnostic Data in the Abbreviated RAPS Format from Medicare Advantage Organizations for Risk Adjusted Payments; more

On March 2, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:

Notice of Denial of Medicare Prescription Drug Coverage
Collection of Diagnostic Data in the Abbreviated RAPS Format from Medicare Advantage Organizations for Risk Adjusted Payments
Emergency and Non-Emergency Ambulance Transports and Beneficiary Signature Requirements
End Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations

Comments are due to the OMB desk officer by April 1, 2020.

Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare

On March 3, CMS published Special Edition MLN Matters 20009 regarding clarification of Medicare policy which provides cost plan enrollees with coverage both through the Medicare cost plan and through original Medicare. CMS has received reports from Medicare cost plans that non-network providers sometimes will not treat cost plan members because of payer issues.

NCD 20.4 Implantable Cardiac Defibrillators (ICDs)

On March 3, CMS published Special Edition MLN Matters 20006 regarding concerns that were voiced about the NCD for ICDs. The article clarifies confusion over why certain heart failure codes are included and whether active heart failure is necessary for coverage, whether certain coding principles are followed, whether the coding requirements are more restrictive than the NCD, and more.

Updated Corporate Integrity Agreement Documents

On March 3, the OIG published information on new Corporate Integrity Agreements with:

Aventis, Inc., Sanofi US Services, Inc., Sanofi-Aventis US, LLC, and Genzyme Corporation, of Cambridge, MA
Guardian Healthcare Management Services, LLC and Guardian Healthcare Ancillary Services Holdco, LLC
Cookeville Regional Medical Center Authority, of Cookeville, TN

Updated Provider Self-Disclosure Settlements

On March 4, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

On February 3, VHS Harlington Hospital Company, LLC d/b/a Valley Baptist Medical Center, of Texas, reached a $159,084.25 settlement agreement with the OIG to resolve allegations that it employed an individual it knew or should have known was excluded from participation in federal health care programs.
On February 7, INTEGRIS Miami Hospital d/b/a INTEGRIS Miami EMS, of Oklahoma, reached a $109,943.43 settlement agreement with the OIG to resolve allegations that it employed an EMT whose license was expired, and it had submitted claims to Medicare and Medicaid for emergency services that did not meet applicable federal and state requirements.
On February 10, Smartbox Assistive Technology, Inc., of Pennsylvania, reached a $50,000 settlement agreement to resolve allegations that it paid remuneration to independent contractors in the form of sales commissions in exchange for the independent contractors’ referrals of DMEPOS to Smartbox that were payable under the Medicare/Medicaid programs.
On February 18, the City of Lincoln, Nebraska d/b/a Lincoln Fire & Rescue, reached a $49,122.27 settlement agreement with the OIG to resolve allegations that it employed an unlicensed individual to provide paramedic services that were paid for by federal health care programs.
On February 19, Interim HealthCare of Southeastern Colorado, of Colorado, reached a $308,312.38 settlement agreement with the OIG to resolve allegations that it submitted claims for payment to Medicare and Medicaid based on falsified orders.
On February 26, The Regents of the University of California on behalf of the University of California Los Angeles Health System, of California, reached a $241,033.41 settlement agreement with the OIG to resolve allegations that it submitted claims for services provided by a physician when the services were actually provided by international fellows or ACGME residents and domestic fellows outside the physician’s physical presence and without his supervision.

Suspension of Survey Activities

On March 4, CMS published a Memorandum to state survey agency directors regarding changes to survey protocol in response to the threat of coronavirus. CMS is limiting survey activity solely to immediate jeopardy complaints, allegations of abuse and neglect, complaints involving infection control concerns, statutorily required recertification surveys, and other special situations in order to focus effort appropriately on preventing the spread of coronavirus. CMS published a Press Release on the memorandum on the same date.

Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.

Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge

On March 4, CMS published a Memorandum to state survey agency directors regarding guidance on infection control and caring for patients with COVID-19 or potential cases of COVID-19. The memorandum discusses how to handle issues such as screening visitors or patients for the virus, monitoring and/or restricting health care facility staff, how to handle the needs of patients who have been diagnosed with COVID-19, discharge planning considerations, and more. The memorandum also includes links to multiple resources on the virus. CMS published a Press Release on the memorandum on the same date.

Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the State/Regional Office training coordinators immediately.

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes

On March 4, CMS published a Memorandum to state survey agency directors regarding guidance on infection control and prevention of COVID-19 in nursing homes. The memorandum discusses how facilities should handle visitors, how to monitor or restrict staff, when to consider transferring a resident with suspected or confirmed COVID-19 to a hospital, when to accept a resident with COVID-19 from a hospital, and more. The memorandum also provides links to multiple resources on infection control and prevention of COVID-19. CMS published a Press Release on the memorandum on the same date.

Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators immediately.

Medicare Hospital Provider Compliance Audit: Saint Francis Health Center

On March 4, the OIG published a Review of whether Saint Francis Health Center complied with Medicare requirements for billing inpatient services on selected types of claims dating from January 1, 2015, through December 31, 2016. Of the 100 claims included in the review, the OIG found that Saint Francis did not comply with Medicare billing requirements for 51 claims. The issues involved 44 claims that did not meet medical necessity requirements for acute inpatient rehabilitation and seven claims that were incorrectly coded and resulted in inaccurate DRG payments. On the basis of the sample, the OIG estimated that the hospital received overpayments of at least $5.5 million during the audit period.

The OIG recommends Saint Francis refund the Medicare contractor at least $5.5 million, identify and return any similar overpayments, and strengthen controls to ensure full compliance with Medicare requirements. Saint Francis disagreed with the OIG’s findings for five of the nine claims that were initially found to be incorrectly coded and disagreed with all claims that the OIG determined did not meet acute inpatient rehab medical necessity requirements. It claimed the independent medical review contractor made numerous errors, including using an incorrect standard of review, ignoring important clinical information, using 20/20 hindsight, and more. The OIG reduced the number of incorrectly coded claims from nine down to seven but otherwise did not change any of its findings.

Comment Request: Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form; more

On March 6, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:

Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form
Reconciliation of State Invoice (ROSI) and Prior Quarter Adjustment Statement (PQAS)

Comments are due to the OMB desk officer by April 6, 2020.

April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

On March 6, CMS published Medicare Claims Processing Transmittal 4544 regarding changes implemented in the April 2020 OPPS update. This includes several changes to proprietary laboratory analyses codes, new status indicators associated with the NCD for acupuncture and dry needling, implementation of the new coronavirus lab test HCPCS code (U0001), and more.

Effective date: April 1, 2020