This week in Medicare updates—5/15/2019

May 15, 2019
Medicare Insider

Updated Provider Self-Disclosure Settlements

On May 6, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

  • On April 1, Mid-Florida Pathology, LLC, and Laboratory Services of Central Florida, LLC, of Florida, agreed to a $314,497.41 settlement with the OIG after self-disclosing conduct violating Civil Monetary Penalties law provisions applicable to kickbacks by paying remuneration to Orlando Foot & Ankle Clinic, Inc. pursuant to arrangements for the provision of laboratory services. Also on April 1, Orlando Foot & Ankle Clinic, Inc., of Florida, agreed to a $418,256.66 settlement with the OIG after self-disclosing conduct violating Civil Monetary Penalties law provisions applicable to kickbacks by receiving remuneration from Mid-Florida Pathology, LLC, and Laboratory Services of Central Florida, LLC, pursuant to arrangements for laboratory services.
  • On April 3, The Vicksburg Clinic, LLC d/b/a Merit Health Medical Group, of Mississippi, agreed to a $2,022,904.96 settlement with the OIG after self-disclosing conduct related to submitting claims for inpatient behavioral health services when the medical record did not support medical necessity or the level of care billed and there was documentation cloning for multiple dates of treatment for the same patients and for multiple patients on the same date of treatment.
  • On April 4, Great River Health System, Inc., Great River Foundation, Riverview System, Inc., Great River Medical Center, and Great River Physicians and Clinics, Inc., of Iowa, reached a $3,008,326.50 settlement with the OIG after it self-disclosed conduct related to paid remuneration to a physician in the form of excessive compensation. The groups are also alleged to have submitted false claims to Medicare, Medicaid, and Tricare for medically unnecessary and improperly coded hyperbaric oxygen therapy and wound care services provided by the physician.
  • On April 9, Winchester Radiologists, PC, of Virginia, reached a $1,673,415 settlement with the OIG after it self-disclosed conduct related to submitting claims to Medicare, Medicaid, Tricare, and the Veteran’s Administration for non-diagnostic surgical and invasive procedures performed by a radiologist practitioner assistant at two hospitals and their outpatient centers and not eligible for reimbursement.
  • On April 10, Carolina Eye Center, P.A., of South Carolina, reached a $15,040.25 settlement with the OIG after it self-disclosed conduct related to billing Medicare for two physicians’ services claiming they were rendered incident-to the services of a third physician when such services did not meet Medicare’s incident-to billing requirements and were not furnished by providers properly enrolled in Medicare.

 

Final Rule: Changes to the Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedures

On May 7, CMS published a Final Rule in the Federal Register regarding regulations for appealing adverse determinations regarding claims for benefits under Medicare Part A, Part B, or prescription drug coverage under Part D. Provisions of the rule include removing the requirement that appellants sign appeal requests and changing the timeframe for vacating dismissals from months to calendar days. The rule also includes technical corrections to help ensure regulations are clearly arranged and written so stakeholders will have a better understanding of the appeals process.

Dates: These regulations are effective on July 8, 2019.

 

Home Health Change of Care Notice Update

On May 9, CMS published new Home Health Change of Care Notice forms for download on its website. Effective July 1, 2019, all home health agencies will be required to use the renewed for with the expiration date of 4/30/2022 on the bottom of the page. There have been no changes made to the form other than the expiration date.

 

Reporting the Patient Relationship Categories and Codes

On May 10, CMS published One-Time Notification Transmittal 2300 regarding the HCPCS Level II code modifiers to report for Patient Relationship Categories and Codes (PRC). These codes are currently voluntary, but MACRA requires that they become mandatory on claims, which CMS said will happen in the near future. Medicare Part B Merit-based Incentive Payment System (MIPS)-eligible clinicians may report their patient relationships on Medicare claims using PRCs X1, X2, X3, X4, and X5.   

Effective date: January 1, 2018

Implementation date: August 12, 2019

 

Final Rule: Regulation to Require Drug Pricing Transparency

On May 10, CMS published a Final Rule in the Federal Register regarding amendments to regulations for Federal Health Insurance Programs for the Aged and Disabled to require that direct-to-consumer (DTC) television advertisements for prescription drugs and biologicals reimbursed by Medicare or Medicaid include the list price of that product if the price for a 30-day supply or typical course of treatment is $35 or more. The required list price must be displayed as legible text that can be read easily at the end of the advertisement.

Dates: This rule is effective July 9, 2019.

 

Implementation to Send Pre-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System

On May 10, CMS published One-Time Notification Transmittal 2302 regarding implementation of files and changes that will support sending ADR letters electronically as Pre-Pay eMDRs.

Effective date: January 1, 2020

Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation

 

Implementation to Send Post-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System

On May 10, CMS published One-Time Notification Transmittal 2305 regarding implementation of changes to generate and send the ADR Letter Package information to esMD so these letters can be sent electronically as Post-Pay eMDRs. These instructions do not apply to any post-pay ADRs generated based on appeals (either medical or non-medical review related) or Post-Pay ADRs generated for participants by the Medicare as Secondary Payer contractor.

Effective date: January 1, 2020

Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation