This week in Medicare updates—4/10/2019

April 10, 2019
Medicare Insider

2020 Medicare Advantage and Part D Rate Announcement and Final Call Letter

On April 1, CMS published the 2020 Medicare Advantage and Part D Rate Announcement and Call Letter. The notice provides final policy and payment updates to the Medicare Advantage and Part D program. Some of the finalized policies include:

  • Risk adjustment - finalizing implementation of the alternative payment condition count model which includes additional condition categories for pressure ulcers and dementia, as well as additional variables counting the number of conditions a beneficiary may have
  • Risk scores - calculate these for 2020 by adding 50% of the risk score calculated using diagnoses from encounter data, RAPS inpatient diagnoses, and FFS diagnoses, and 50% of the risk score calculated with diagnoses from RAPS and FFS diagnoses
  • Drug utilization review - creating additional policies to prevent and combat prescription opioid overuse, such as pain management and complementary and integrative treatments as well advancing opioid-related measures through the star ratings development process
  • Special supplemental benefits for chronically ill - The Bipartisan Budget Act of 2018 amended a statute which will now allow Medicare Advantage to offer supplemental benefits, such as transportation and home environment services, that are not primarily health-related but would have a reasonable expectation of improving or maintaining the health and overall function of patients with chronic conditions/illnesses

CMS published a Press Release and Fact Sheet on the Rate Announcement and Final Call Letter on the same date.


Claim Rejection and Denials for Providers on the Preclusion List to begin on April 1, 2019

On April 1, CMS published a Fact Sheet regarding the Preclusion List, which is used to identify providers and prescribers who are precluded from receiving payment for Medicare Advantage/Part D items, services, and drugs as furnished or prescribed to Medicare beneficiaries. The fact sheet details the two categories individuals or entities could fall into on the preclusion list. It also discusses processes related to the preclusion list’s release.


Updated Provider Self-Disclosure Settlements

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

  • On March 21, Redstone Presbyterian SeniorCare, of Pennsylvania, reached a $25,878.91 settlement with the OIG to resolve allegations that it presented claims to Medicare for services performed by a physical therapy assistant without the required direct supervision.


Updates to Medicare Financial Management Manual Chapter 4, Section 50-50.6 Extended Repayment Schedules

On April 5, CMS published Medicare Financial Management Transmittal 312 regarding updates and clarification to the extended repayment schedule (ERS). These updates include changes to steps that should be implemented upon receipt of an ERS, multiple changes to the steps for reviewing and establishing an ERS, details on good faith payments, and more.

Effective date: October 1, 2019

Implementation date: October 7, 2019


Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2019

On April 5, CMS published Medicare Claims Processing Transmittal 4275 regarding the quarterly update of the DME CBP files.  

Effective date: July 1, 2019

Implementation date: July 1, 2019