This week in Medicare updates—6/13/18

June 13, 2018
Medicare Insider

Increases in Reimbursement for Brand-Name Drugs in Part D

On June 4, the OIG published a Review on how increases in reimbursement for brand-name drugs in Part D may be affecting Medicare and its beneficiaries by looking at data from 2011-2015. The OIG found that there were fewer prescriptions for brand-name drugs in 2015 than in 2011, but the total reimbursement for all brand-name drugs in Part D increased by 77% from 2011 to 2015. The OIG also found that the average unit cost for brand-name drugs in Part D rose nearly six times faster than inflation from 2011 to 2015. Because plan sponsors base their pharmacy reimbursement amounts on prices manufacturers set for those drugs, the OIG concluded that increasing manufacturer prices for brand-name drugs may result in these increasing costs for Medicare and its beneficiaries.


2017 Performance Data for the Senior Medicare Patrol Projects

On June 5, the OIG published a Review of the Senior Medicare Patrol (SMP) projects for 2017. The review concluded that the SMP program continued to grow, reaching 400,000 more people in 2017 than it did in 2016. It also reported significantly higher amounts for expected Medicare recoveries than in previous years, as expected Medicare recoveries totaled $2,010,475 in 2017, which is much more than the $2,672 recorded in 2016. This huge jump in recoveries was primarily due to a Nevada project that prompted law enforcement to open an investigation into a hospice company, which ultimately resulted in a large settlement with the OIG.  


Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items that Require Prior Authorization as a Condition of Payment

On June 5, CMS published a Notice in the Federal Register to announce the addition of 31 HCPCS codes for durable medical equipment items to the DMEPOS Required Prior Authorization List.

Dates: Implementation is effective on September 1, 2018.  


Decline in Hospital-Acquired Conditions Saves 8,000 Lives and $2.9 Billion in Costs

On June 5, CMS issued a Press Release and Fact Sheet regarding data from the Agency for Healthcare Research and Quality (AHRQ) on patient safety. The data shows continued success in national efforts to reduce hospital-acquired conditions, as the AHRQ said these initiatives saved 8,000 lives and $2.9 billion between 2014 and 2016. The AHRQ national scorecard on hospital-acquired conditions estimates that 350,000 hospital-acquired conditions were avoided in that same time period, reducing the rate of those conditions by 8%. CMS has set a goal to reduce hospital-acquired conditions by 20% between 2014 and 2019.


New Provider Self-Disclosure Settlements

On June 6, the OIG updated its list of Provider Self-Disclosure Settlements reached in May. The list includes:

  • On May 9, Advanced Urology Institute, LLC, of Florida, reached a $716,518.89 settlement with the OIG for allegedly submitting claims to Medicare and Medicaid for radiation oncology services without providing the requisite level of physician supervision.
  • On May 14, Kettering Medical Center d/b/a Kettering Behavioral Medicine Center, of Ohio, reached a $1,298,249 settlement with the OIG for allegedly submitting claims for group psychotherapy services provided by unlicensed mental health technicians.
  • On May 14, Chesapeake Eye Care and Laser Center, P.C., of Maryland, reached a $613,617.39 settlement with the OIG for allegedly improperly billing for services rendered by new providers under already-credentialed providers’ Medicare Provider Transaction Access Numbers or National Provider Numbers.
  • On May 14, Bronx Physical Therapy and Rehabilitation, of New York, reached a $13,587 settlement for allegedly submitting claims for services provided by an unlicensed physical therapist.
  • On May 15, Visionworks of America, Inc., f/k/a Eye Care Centers of America, Inc.; Visionary Properties, Inc.; Visionworks, Inc.; Eyemasters, Inc.; and Empire Vision Center, Inc., of Texas, reached a $3,668,961 settlement with the OIG for allegedly paying excess remuneration to optometrists in the form of space and equipment leases below fair market value and/or by failing to collect rent under space and equipment leases.
  • On May 15, Cheyenne Regional Medical Center, of Wyoming, reached a $2,099,462.30 settlement with the OIG for allegedly paying remuneration to a physician practice pursuant to a Practice Lease Agreement where the remuneration was greater than fair market value or was for costs that the physician practice should have borne.
  • On May 15, Monadnock Community Hospital, of New Hampshire, reached a $498,717 settlement with the OIG for allegedly submitting claims to Medicare for technical services associated with transthoracic echocardiograms performed by two non-credentialed individuals.
  • On May 15, County of Sullivan and Sullivan County Ambulance Services, of Indiana, reached a $10,000 settlement with the OIG for allegedly submitting claims for reimbursement to Medicare for ambulance services provided by an employee crew member who lacked a current EMT certification for the State of Indiana.
  • On May 21, Aspen Trace Health and Living Community, of Indiana, reached a $16,115.25 settlement with the OIG for allegedly employing an individual it knew or should have known was excluded from participation in federal health care programs.
  • On May 23, Millenium Healthcare Management, Inc., of Louisiana, reached a $321,411 settlement with the OIG for allegedly submitting claims at urgent care centers that were not supported by sufficient documentation to justify the code level due to inadequate detail on patient family and social history as well as insufficient detail to support the inclusion of medical decision-making as a component in determining the code level.


Recent and Upcoming Improvements in Hospice Billing and Claims Processing

On June 7, CMS published Special Edition MLN Matters 18007 to review the recent and upcoming Medicare improvements to hospice billing and claims processing. Some of the topics discussed include submitting notices of election via electronic data interchange, correcting election or revocation dates using occurrence code 56, a new election period file and screen, changes to election period or benefit period information, and more.   

Effective date: N/A

Implementation date: N/A


July Quarterly Update for 2018 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

On June 8, CMS published Medicare Claims Processing Transmittal 4072 to implement changes for the July quarterly update to the DMEPOS fee schedule. The transmittal contains instructions for the DMEPOS fee schedule file and CY 2018 DMEPOS Rural ZIP code file, but there is no change to the PEN fee schedule file for Quarter 3, so it is not included in the update. There are also instructions on how to treat claims for HCPCS codes with revised 50/50 blend fees appearing on the July 2018 DMEPOS FI file.

Effective date: July 1, 2018 - January 1, 2018 for implementation of fees for code Q0477; June 1, 2018 for CMS-1687-IFC-related rural and non-contiguous blended fees on the FI file; July 1, 2018 for all other changes.

Implementation date: July 2, 2018


Update of Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 18- Preventive and Screening Services, and Chapter 35 - Independent Diagnostic Testing Facility (IDTF)

On June 8, CMS published Medicare Claims Processing Transmittal 4071 to update two chapters of the IOM with requirements and payment policies for screening mammography services furnished by IDTFs.

Effective date: July 9, 2018

Implementation date: July 9, 2018


Alignment of Coordination of Benefits Agreement (COBA) Internet Only Manual References

On June 8, CMS published Medicare Claims Processing Transmittal 4069 regarding changes to Chapter 28 of the Claims Processing Manual to ensure it properly references newly numbered sections in Chapter 27. CMS recently updated Chapter 27 of the manual and renumbered certain sections of that chapter in the process. The transmittal also ensures changes are made to Chapter 28 to reference the Benefits Coordination & Recovery Center (BCRC) instead of the Coordination of Benefits Contractor (COBC).

Effective date: July 9, 2018

Implementation date: July 9, 2018


Updated Corporate Integrity Agreement Documents

On June 8, the OIG published information on several closed Corporate Integrity Agreements. The closed agreements include:

  • Associates in Eye Care, P.S.C., of Williamsburg, KY
  • Atrium Medical Center f/k/a Middletown Regional Hospital, of Dayton, OH
  • Boehringer Ingelheim Pharmaceuticals, Inc., of Ridgefield, CT
  • Huang, Benson Yu, MD, of Laredo, TX
  • International Rehabilitative Sciences, Inc., d/b/a RS Medical, Vancouver, WA
  • Shen, John, M.D.; Albemarle Women’s Clinic PA, of Albemarle, NC
  • WakeMed Raleigh Campus, of Raleigh, NC


Updated List of Excluded Individuals and Entities (LEIE)

On June 8, the OIG updated its LEIE with an updated LEIE database for download and lists of May 2018 exclusions, reinstatements, and profile corrections.


Final Rule: Changes to the Comprehensive Care for Joint Replacement (CJR) Payment Model: Extreme and Uncontrollable Circumstances Policy for the CJR Model

On June 8, CMS published a Final Rule in the Federal Register to finalize a policy to provide flexibility in the determination of episode spending for CJR participant hospitals located in areas impacted by extreme and uncontrollable circumstances for performance years three through five.

Effective date: July 9, 2018