This week in Medicare updates—3/2/2022
Hospitals Did Not Always Meet Differing Medicare Contractor Specifications for Bariatric Surgery
On February 23, the OIG published a Review of whether hospitals’ inpatient claims for bariatric surgeries met Medicare national requirements and Medicare contractors’ eligibility specifications. The OIG found that out of 120 claims they reviewed, 32 claims did not meet eligibility specifications (although they did meet the NCD requirements) and one claim did not meet NCD requirements. An additional claim was not reviewed but was not considered an error because it was under review by a CMS contractor. The OIG also found that claims from MAC jurisdictions with more restrictive specifications in the LCDs/LCAs were more likely to fail to meet specifications. The specifications also varied among MACs, which the OIG said was due to Medicare’s NCD requirements not being specific. The OIG estimates that Medicare could have saved $47.8 million during the audit period if Medicare contractors had disallowed claims that did not meet NCDs or contractor specifications for bariatric surgery.
The OIG recommends CMS determine whether any of the eligibility specifications from the LCDs/LCAs should be added to the NCD for bariatric surgery, work with contractors to review whether any eligibility specifications should be requirements rather than guidance, and educate hospitals on the NCD requirements for bariatric surgeries if CMS decides to update the NCD to make it more specific. CMS did not agree with the OIG’s recommendations, and it noted that there may be valid reasons for variation in LCD guidance at the local Medicare contractor level.
CMS Redesigns Accountable Care Organization (ACO) Model to Provide Better Care for People with Traditional Medicare
On February 24, CMS published a Press Release to announce it is redesigning an ACO–the Global and Professional Direct Contracting (GPDC) Model–and renaming it the Realizing Equity, Access, and Community Health (REACH) Model. The model will continue to run as the GPDC Model until December 31, 2022, then will transition into the REACH Model on January 1, 2023. Effective immediately, CMS is also canceling the Geographic Direct Contracting Model, which had been announced in December 2020 and paused in March 2021.
CMS published a Fact Sheet on the model and a Table comparing ACO REACH and GPDC on the same date.
Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)
On February 24, CMS published Medicare Claims Processing Transmittal 11278 regarding implementation of the transitional drug add-on payment adjustment (TDAPA) for HCPCS code J0879 effective April 1, 2022.
Effective date: April 1, 2022
Implementation date: April 4, 2022
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for FY 2020 for IPPS Hospitals, Inpatient Rehabilitation Facilities (IRF), and Long-Term Care Hospitals (LTCH)
On February 24, CMS published Medicare Contractor Beneficiary and Provider Communications Transmittal 11276 regarding updated SSI/Medicare beneficiary data for determining the disproportionate share hospital (DSH) adjustment for IPPS hospitals, the low-income patient (LIP) adjustment for IRFs, and payments applicable for LTCH discharges.
CMS published MLN Matters 12628 on the same date to accompany the transmittal.
Effective date: March 25, 2022
Implementation date: March 25, 2022
CY 2022 Medicare Swing-Bed SNF Rates
On February 25, CMS published Medicare Provider Reimbursement Transmittal 489 regarding updates to Table 33 to add in the calendar year 2022 payment rates for routine SNF-type services by swing-bed hospitals.
Effective date: For services furnished on or after January 1, 2022