This week in Medicare updates—3/13/2019

March 13, 2019
Medicare Insider

Interoperability and Patient Access Proposed Rule

On March 4, CMS published a Proposed Rule in the Federal Register regarding interoperability and patient access. The rule is focused on advancing interoperability and patient access to health information by creating ways to make patient data more useful and transferable through open, secure, standardized, and machine-readable formats. The rule was previously discussed in a Fact Sheet published February 11, but dates for comments were not available until publication in the Federal Register.

Comments on the proposed rule are due no later than 5 p.m. on May 3, 2019.


Revisions to Appendix Q, Guidance on Immediate Jeopardy

On March 5, CMS published a Memorandum to state survey agency directors regarding substantial revisions to Appendix Q of the State Operations Manual which provides guidance on immediate jeopardy. The revisions include the formation of a Core Appendix Q to be used by surveyors of all provider and supplier types as well as subparts of the appendix focusing on immediate jeopardy concerns specific to long-term care and clinical laboratories. Some of the key changes in the Core Appendix Q include using the term “likelihood” instead of “potential” for what might constitute immediate jeopardy, removing the requirement of culpability to cite immediate jeopardy, including a section on psychosocial harm, and clarifying that there are no automatic immediate jeopardy citations.

On March 6, CMS published State Operations Provider Certification Transmittal 187 regarding the changes to Appendix Q.

Effective date: March 6, 2019

Implementation date: March 6, 2019


April 2019 Improvements to Nursing Home Compare and the Five Star Rating System

On March 5, CMS published a Memorandum to state survey agency directors regarding improvements to the three rating domains used in the Five Star Quality Rating System for the Nursing Home Compare website. These include ending the freeze on including facility inspections in a facility’s overall star rating calculation, instituting multiple changes to the quality measure domain, establishing new thresholds for staffing ratings, and reducing the threshold for the number of days without an RN onsite that triggers an automatic downgrade to one star.

CMS issued a Press Release regarding these changes on the same date.

Effective date: April 24, 2019. 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.


National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)

On March 6, CMS published National Coverage Determinations Transmittal 214, which rescinds and replaces Transmittal 210, dated November 30, 2018, to extend the implementation date by 30 days and update the attached diagnosis code list. The original transmittal was issued to notify contractors that, effective March 16, 2018, CMS will cover diagnostic lab tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.

Effective date: March 16, 2018

Implementation date: April 8, 2019 - 120 days from issuance of initial CR10878 issued on 11/30/18 - A/B MACs


Advisory Opinion No. 19-03

On March 6, the OIG published an Advisory Opinion on whether a program offered by a medical center that provides free, in-home follow-up care to individuals with congestive heart failure and, through a program expansion, chronic obstructive pulmonary disease would constitute grounds for the imposition of sanctions under civil monetary penalties prohibiting inducements to beneficiaries or the anti-kickback statute. The goals of this arrangement would be to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions. The OIG determined it would not impose sanctions in this case because the benefits outweigh the risk of any inappropriate patient steering, the arrangement is unlikely to lead to increased costs to federal health care programs or patients, there is a low risk that the arrangement would skew clinical decision-making, the arrangement would not be marketed to the public, and the scope and duration of the services are reasonably tailored to accomplish its main goals.


DMEPOS Competitive Bidding Round 2021

On March 8, CMS published a Fact Sheet regarding updates to the DMEPOS Competitive Bidding Program for CY 2021. These updates affect competitive bidding areas, shifting product categories, lead item pricing, single payment amounts, bid surety bonds, and more.


Updated Provider Self-Disclosure Settlements

On March 8, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

  • On February 6, Omenihu Oluikpe, of New York, reached a $50,000 settlement with the OIG to resolve allegations that Oluikpe submitted or caused a pharmacy he owned to submit claims to CMS for only the base of compounded medications when he actually dispensed compounded medications made with bulk powder.
  • On February 19, Union Hospital of Cecil County, Inc., of Maryland, reached a $457,213.07 settlement with the OIG to resolve allegations that it paid remuneration to physicians in the form of free support services provided by physician assistants and paid remuneration to cardiologists in the form of free support services provided by a nurse practitioner.


Medicare Provider Reimbursement Manual Part 2, Provider Cost Reporting Forms and Instructions, Chapter 42, Form CMS-265-11

On March 8, CMS published Provider Reimbursement Manual Transmittal 5 regarding updates to the Independent Renal Dialysis Facility Cost Report, Form CMS-265-11, by clarifying and correcting the existing instructions, forms, and electronic cost report specifications.

Effective date: ESRD changes effective for cost reporting periods ending on or after January 31, 2019.