This week in Medicare updates—4/17/2019
CY 2020 Medicare Advantage and Part D Flexibility Final Rule
On April 5, CMS published a Final Rule regarding updates to the Medicare Advantage and Part D Prescription Drug Benefit programs that implement provisions of the Bipartisan Budget Act of 2018, improve program quality and accessibility, and clarify program integrity policies. One of the most significant policies finalized involves expanded telehealth benefits which, as enabled by the Bipartisan Budget Act, would allow MA beneficiaries to access telehealth services from places such as their homes, and afford MA plans broader flexibility in how to pay for telehealth benefit coverage.
CMS published a Press Release and Fact Sheet on the final rule on the same date.
Effective date: These regulations are effective on January 1, 2020, except for certain amendments listed in the text of the final rule.
Medicare Quarterly Provider Compliance Newsletter
On April 8, CMS published the April issue of the Medicare Quarterly Compliance Newsletter. This edition of the newsletter discusses insufficient documentation for billing intravenous immune globulin (IVIG) treatment and correct reporting of untimed therapy units.
Updated Stipulated Penalties and Exclusion for Material Breach
On April 8, the OIG updated its list of Stipulated Penalties and Exclusion for Material Breaches with one new action:
- On April 3, Tri-County Ambulance was excluded for a period of five years based on a breach of its Corporate Integrity Agreement. The OIG had issued a letter on November 9, 2018, demanding stipulated penalties of $25,000 based on Tri-County’s failure to submit its Annual Report. Tri-County did not pay the penalty, nor did it respond to the OIG’s notice of material breach and intent to exclude in January 2019.
Comment Request: Indirect Medical Education and Direct Graduate Medical Education; Information Collection Requirements Associated with Drug Pricing Transparency and Supporting Regulations in 42 CFR 403.1202
On April 8, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Indirect Medical Education and Direct Graduate Medical Education
- Information Collection Requirements Associated with Drug Pricing Transparency and Supporting Regulations in 42 CFR 403.1202
Comments are due by June 7, 2019.
Nationwide Brace Scam Responsible for Over $1.2 Billion in Losses
On April 9, the OIG and Department of Justice published a Press Release regarding charges filed against 24 individuals involved in what the FBI is calling one of the largest health care fraud schemes in history. The scheme revolves around a nationwide brace scam involving international shell companies and fraudulent telemedicine companies that led to more than $1.2 billion in losses. CMS announced on the same date that it took adverse administrative action against 130 durable medical equipment (DME) companies that had submitted over $1.7 billion in claims and were paid over $900 million. The scheme involved payment of illegal kickbacks and bribes by DME companies in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for back, shoulder, wrist, and knee braces that were medically unnecessary. Defendants allegedly paid doctors to prescribe these braces either without any patient interaction or with only brief telephone conversations with patients they had never seen or met. Proceeds from the scheme were allegedly laundered through international shell companies.
Charges were filed against defendants in New Jersey, Florida, Texas, Pennsylvania, South Carolina, and California. The FBI is continuing to investigate this scheme and has asked doctors and/or medical professionals involved in potentially fraudulent telemedicine and DME marketing schemes with companies such as Video Doctor USA, AffordADoc, Web Doctors Plus, Integrated Support Plus, and First Care MD to call the FBI hotline at 1-800-CALL-FBI.
Proposed Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM)
On April 9, CMS published a Proposed Decision Memo regarding an NCA for ABPM. It proposes coverage of ABPM once per year for suspected white coat hypertension and suspected masked hypertension. By publishing the proposed decision memo, CMS is initiating a 30-day public comment period on the policy.
CMS published a Press Release on the proposed decision memo on the same date.
Updated List of Excluded Individuals and Entities (LEIE)
On April 10, the OIG updated its LEIE with an updated LEIE database for download and lists of March 2019 exclusions, reinstatements, and profile corrections.
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
On April 10, CMS published National Coverage Determinations Transmittal 215, which rescinds and replaces Transmittal 214, dated March 6, 2019, to incorporate missing CPT codes on the diagnosis code attachments. 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
Implementation of the Skilled Nursing Facility (SNF) Patient-Driven Payment Model (PDPM)
On April 11, CMS published One-Time Notification Transmittal 2278, which rescinds and replaces Transmittal 2270, dated March 13, 2019, to add business requirements 11152.9 and 11152.10. The original transmittal was issued regarding the implementation of PDPM.
CMS revised MLN Matters 11152 on March 14 to accompany the transmittal.
Effective date: October 1, 2019
Implementation date: July 1, 2019 - CWF and FISS Coding and Testing in July 2019; July 1, 2019 - CWF Implementation in July; October 1, 2019 - Pricer updates and continue testing
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 3rd Qtr Notification for FY 2019
On April 11, CMS published Medicare Financial Management Transmittal 313 regarding the quarterly change in interest rate for overpayments and underpayments. The private consumer rate has been changed to 10.375% for the third quarter of FY 2019.
Effective date: April 17, 2019
Implementation date: April 17, 2019
New Waived Tests
On April 12, CMS published Medicare Claims Processing Transmittal 4277 regarding 12 newly added waived complexity tests. The CPT codes, effective dates, and descriptions for these tests are listed in the transmittal.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Pub. 100-04, Chapter 29 - Appeals of Claims Decisions - Revisions
On April 12, CMS published Medicare Claims Processing Transmittal 4278 regarding several revisions to Chapter 29 of the manual related to appealing claims decisions. Some of the revisions include policy updates regarding electronic signatures, limiting scope of redetermination review, application of good cause for late filing when there is a declared disaster, and more.
Effective date: June 13, 2019
Implementation date: June 13, 2019