This week in Medicare updates—6/19/2019
Extension: Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
On June 11, CMS published an Extension of Timeline for Publication of Final Rule in the Federal Register to announce it is extending the timeline for publishing the Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care final rule to June 16, 2020. The proposed rule was published June 16, 2016, but CMS is extending the deadline due to the complexity of the rule, its substantive nature, and the scope of comments received.
Updated Provider Self-Disclosure Settlements
On June 11, the OIG published an updated List of Provider Self-Disclosure Settlements, including:
- On April 12, Atrius Health, Inc., of Massachusetts, reached a $222,535.47 settlement agreement with the OIG to resolve allegations that it billed for certain injections of Neulasta under Part B’s incident-to conditions of coverage when the drug was not being administered by a physician or auxiliary personnel.
- On May 22, Kali Nagabalaji, LLC, formerly d/b/a Saginaw Pharmacy; and others, of Texas, reached a $543,664.28 settlement agreement with the OIG to resolve allegations of paying remuneration in the form of commissions for the first fill of certain prescriptions to Bedolla Enterprises, who paid a portion of that to certain practitioners in exchange for referrals of such prescriptions. The OIG also alleged Saginaw Pharmacy knowingly paid remuneration to a marketer in the form of commissions in exchange for arranging for prescriptions to be filled at Saginaw Pharmacy for the patients of two practitioners.
Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements
On June 12, the OIG published a Review of whether Medicare made payments to providers for polysomnography services that did not meet Medicare billing requirements. The OIG found that, of the 200 beneficiaries sampled and the 426 corresponding lines of service, Medicare inappropriately made payments for 83 beneficiaries with 150 corresponding lines of service that did not meet Medicare requirements. The OIG estimates that Medicare made $269 million in overpayments for polysomnography during the audit period of January 1, 2014 through December 31, 2015. These errors occurred because CMS’ oversight of polysomnography was insufficient for ensuring provider compliance with Medicare requirements and could not properly prevent payment of claims that did not meet those requirements. Due to a lack of periodic reviews of claims for these services, MACs were unable to determine whether providers had received payments for these claims and could not take remedial action. The OIG recommends that CMS instruct MACs to recover identified overpayments and conduct data analysis allowing for targeted reviews of claims for these services. It also recommends CMS provide additional education on how to properly bill for these services.
Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated
On June 12, the OIG published a Review of potential incidents of abuse and neglect at skilled nursing facilities (SNF), whether CMS reported findings of substantiated abuse to local law enforcement, and the extent to which CMS records or tracks incidents of potential abuse or neglect. The review is part of a series of OIG reports on incidents of potential abuse and neglect of vulnerable populations. The OIG found that, of the 37,607 high-risk hospital emergency room claims from calendar year 2016 for Medicare beneficiaries residing in SNFs, an estimated one out of every five claims was a result of potential abuse or neglect of a beneficiary residing in a SNF. The OIG determined that SNFs failed to report many of these incidents to survey agencies and that several survey agencies failed to report some findings of substantiated abuse to local law enforcement. The OIG also determined that CMS does not require recording and tracking of all incidents of potential abuse or neglect and related referrals to law enforcement in the Automated Survey Processing Environment Complaints/Incidents Tracking System.
The OIG recommends CMS work with survey agencies to improve training for staff of SNFs on how to identify and report incidents of potential abuse or neglect, clarify guidance to define and provide examples of potential abuse/neglect, require survey agencies to record and track these incidents and any referrals made to local law enforcement, and monitor the survey agencies’ reporting of findings of substantiated abuse to local law enforcement.
CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect
On June 12, the OIG published a Review of the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries. It examines who may have perpetrated these incidents, where they occurred, whether the incidents were reported to law enforcement, and whether CMS also identified similar incidents of potential abuse or neglect during the audit period and took action to address them. The OIG found that 30,754 of a reviewed 34,664 Medicare claims from January 2015 through June 2017 contained at least one of 17 diagnosis codes related to potential abuse or neglect and had associated medical records that supported potential situations of abuse or neglect. The OIG estimated that 2,574 of these claims potentially showed abuse or neglect perpetrated by a healthcare worker, 3,330 were related to incidents occurring in a medical facility, and 9,294 were related to incidents that were not reported to law enforcement. CMS did not identify similar incidents during the audit period because, according to CMS officials, it did not extract data from Medicare claims containing the 17 diagnosis codes related to abuse or neglect.
The OIG recommends CMS compile a complete list of diagnosis codes that indicate potential abuse and neglect, use that list to conduct periodic data extracts of all Medicare claims containing at least one of those codes, inform states that there is extracted Medicare claims data that is available to help states ensure compliance with mandatory reporting laws, and assess the sufficiency of existing federal requirements to report suspected abuse and neglect. CMS did not concur with all of the recommendations, as it said claims data may not be timely enough to address acute problems.
Quarterly HCPCS Drug/Biological Code Changes - July 2019 Update
On June 12, CMS published Medicare Claims Processing Transmittal 4320, which rescinds and replaces Transmittal 4306, dated May 17, 2019, to update the short and long descriptor of Q5115 in the policy section and business requirement 11296.4. The original transmittal was issued regarding the quarterly updates to the HCPCS code set. The July updates include 10 new drug codes, one discontinuation, and one modification.
On May 20, CMS published MLN Matters 11296 to accompany the transmittal.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Updated Corporate Integrity Agreement Documents