This week in Medicare updates—6/20/2018

Provider Enrollment - Unlicensed Residents
On June 8, CMS published Special Edition MLN Matters 18008 to inform unlicensed resident physicians and providers for whom these residents will practice that, effective no later than June 17, 2018, MACs will process CMS Form-855O provider enrollment applications submitted for unlicensed residents if the submission includes either a residency contract signed and dated by both an official of the institution and the resident physician, or a letter on an institution letterhead confirming the applicant’s status as a Resident Physician signed and dated by an official of the institution.

Effective date: N/A

Implementation date: N/A

 

Release of 2019 ICD-10-CM Code Set

On June 11, the CDC posted the Release of the 2019 ICD-10-CM codes for download in both XML and PDF formats. The 2019 update includes a total of 473 code changes, including additions, deletions, and revisions to the code set. Many of the new codes added to the code set are external cause codes to describe exploitation of children and adults in the form of psychological abuse, bullying and intimidation, forced sexual exploitation, or forced labor exploitation. These code changes are effective October 1, 2018 and will be used through September 30, 2019.

 

Most Medicare Claims for Replacement Positive Airway Pressure (PAP) Device Supplies Did Not Comply With Medicare Requirements

On June 12, the OIG published a Review of whether Medicare claims that durable medical equipment (DME) suppliers submitted for replacement PAP device supplies complied with Medicare requirements. The OIG found that only 24 of the 110 claims included in the review’s sample complied with Medicare requirements, resulting in $13,414 in overpayments. Of the 86 claims that did not meet Medicare requirements, 57 sample claims contained more than one error. The most frequent issues with these claims included physician orders that were not in accordance with LCDs (53 errors), suppliers did not have a proper request for replacement supplies (50 errors), suppliers had no proof of delivery (36 errors), and suppliers did not document continued need for PAP device therapy and supplies (22 errors).  

The OIG recommends that CMS recover the overpayments associated with the 86 sample claims that are within the 4-year reopening period. The OIG also makes several recommendations for CMS to work more closely with the four Medicare contractors who processed and paid supplier claims during the sample time.

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On June 13, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusion agreements, including:

• St. Charles Health Council, Inc., of Pennington Gap, Virginia, reached a $115,000 settlement agreement with the OIG on May 30 to resolve allegations that it knowingly presented a specified claim to the Department of Health and Human Services (HHS) under an HHS grant that it knew or should have known was false or fraudulent, and St. Charles knowingly and improperly avoided an obligation to transmit funds to HHS with respect to such a grant.

 

Questions to MEDCAC panel: Chimeric Antigen Receptor (CAR) T-Cell Therapy and Patient Reported Outcomes

On June 14, CMS posted the Questions for the MEDCAC panel regarding the NCD analysis on CAR T-Cell therapy for Medicare beneficiaries with advanced cancer. The panel will be meeting in August to discuss how existing patient reported outcomes (PRO) assessment tools should be incorporated into future clinical studies on CAR T-cell therapies with a focus on specific PRO assessment tools and important characteristics of these tools.

On June 15, CMS published a Notice about the meeting in the Federal Register. The public meeting will be held on Wednesday, August 22, 2018, from 7:30 a.m. until 4:30 p.m. ET.

 

Predictive Qualifying Alternative Payment Model (APM) Participants (QPs) Methodology Fact Sheet

On June 14, CMS published a Fact Sheet on the predictive methodology used to determine Qualifying APM Participant status for the APM branch of the Quality Payment Program for the 2018 performance year. The fact sheet reviews the process CMS used to make these predictions based on the administrative claims with dates of service between 1/1/17 and 8/31/17 that were processed between 1/1/17 and 11/29/17.  

 

Advisory Opinion 18-04

On June 14, the OIG published an Advisory Opinion on a proposed arrangement in which a Medigap plan would contract indirectly with hospitals in a specific network for discounts on the otherwise-applicable Medicare inpatient deductibles for policyholders under the Medigap plans, and in turn, would offer a premium credit of $100 to policyholders who use the network hospitals for an inpatient stay. The OIG analyzed whether the proposed arrangement would violate the anti-kickback statute and/or the prohibition on inducements to beneficiaries. The OIG determined that in the case of this specific arrangement, the OIG would not impose sanctions on the entities involved for violations of the anti-kickback statute and prohibition on inducements to beneficiaries due to a variety of reasons listed in the document.

 

Updated OIG Work Plan

On June 15, the OIG updated its Work Plan with the following new items:

• Accountable Care Organizations' Strategies Aimed at Reducing Spending and Improving Quality
• Medicare Part B Payments for End-Stage Renal Disease Dialysis Services
• National Background Check Program: Assessment of Concluded State Grant Programs in 2017
• Inappropriate Denial of Services and Payment in Medicare Advantage
• Review of Home Health Claims for Services With 5 to 10 Skilled Visits
• Denials and Appeals in Medicare Part D
• CMS's Contingency Planning for Information Technology Systems

 

Corrections: Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-For-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program
On June 15, CMS published a Correction Notice in the Federal Register regarding the CY 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare FFS, the Medicare Prescription Drug Benefit Programs, and the PACE Program final rule. The notice makes numerous corrections to technical and typographical errors identified throughout the final rule.  

Effective date: This correcting document is effective June 15, 2018.

 

Comprehensive Error Rate Testing (CERT) Update to Chapter 12 of Publication (Pub.) 100-08
On June 15, CMS published Medicare Program Integrity Transmittal 800 to update Chapter 12 of the Medicare Program Integrity Manual with more details on how CERT contractors can handle non-responders and insufficient responses to additional documentation requests.

Effective date: July 17, 2018

Implementation date: July 17, 2018

 

Quarterly Update to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)
On June 15, CMS published Medicare Claims Processing Transmittal 4073 to provide instructions for new codes added to the HCPCS file for anemia management which will therefore be added to the list of items and services subject to the ESRD PPS consolidated billing requirements.

Effective date: July 1, 2018

Implementation date: July 2, 2018