This week in Medicare updates—6/2/2021
Collaborative Patient Care is a Provider Partnership
On May 24, CMS revised an MLN Fact Sheet regarding provider documentation best practices to facilitate collaborative care. The revisions include adding the supplemental medical review contractor to the list of Medicare claims audit contractors, a bullet about the impact of incomplete documentation on patient financial responsibility, the deletion of a list of medical directors at the end of the fact sheet, and more.
Updated Home Health Benefit and Payment System Booklets
On May 24, CMS revised an MLN Booklet on the Home Health Benefit and an MLN Booklet on the Home Health Prospective Payment System (HH PPS). Revisions include changes to a section on allowed practitioners, PDGM, and covered home health services. Both booklets had updates on changing the LUPA threshold to a variable threshold. The HH PPS Booklet also had revisions to account for the switch in CY 2022 away from submitting a no-pay RAP to submitting a Notice of Admission (NOA) instead.
Medicare Advantage Compliance Audit of Diagnosis Codes that Anthem Community Insurance Company, Inc. Submitted to CMS
On May 24, the OIG published a Review of whether Anthem submitted diagnosis codes to CMS in accordance with federal requirements for use in the risk adjustment program. The OIG examined a sample of 203 enrollee-years with high-risk diagnosis codes for which Anthem received higher payments. The OIG found that Anthem did not submit diagnosis codes in accordance with federal requirements for 123 of the 203 enrollee-years reviewed, as the OIG said the medical records did not support the associated diagnosis codes. The OIG estimated that Anthem received at least $3.47 million in net overpayments for 2015 and 2016 as a result of this.
The OIG recommends Anthem refund the government for the $3.47 million in net overpayments; identify similar instances of noncompliance and refund any resulting overpayments; and enhance its compliance procedures to focus on diagnosis codes at high risk for being miscoded by determining whether diagnosis codes comply with federal requirements and educating providers on the proper use of these diagnosis codes. Anthem disagreed with the OIG’s findings and recommendations, did not agree with methodologies used to review the select diagnoses and calculate overpayments, and said the OIG report reflects misunderstandings of legal and regulatory requirements underlying the MA program. The OIG stood by its original findings and recommendations.
FAQs: Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the COVID-19 Public Health Emergency
On May 24, the OIG updated an FAQ regarding changes to enforcement for certain arrangements which are directly connected to COVID-19. The new FAQs addresses the implications of providing cash incentives for receiving a COVID-19 vaccination to federal health care program beneficiaries during the PHE.
COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
On May 24, CMS updated the blanket waivers for health care providers Fact Sheet to provide information on an extension to the submission deadline for new and existing Medicare GME affiliation agreements. The deadline to submit both new (for the academic year starting July 1, 2021) and amended (for the academic year ending June 30, 2021) GME affiliation agreements is now January 1, 2022.
COVID-19 Vaccine and Monoclonal Antibody Billing Updates
On May 26, CMS updated several webpages pertaining to vaccine administration and monoclonal antibody billing. Updated pages include:
- Enrollment for Administering COVID-19 Vaccine Shots
- Billing for COVID-19 Vaccine Shot Administration
- Monoclonal Antibody COVID-19 Infusion
Because CMS does not indicate which information on these pages is new, it is best to review the page and associated links in their entirety. One noted update on the Monoclonal Antibody COVID-19 Infusion page is new information related to the circumstances when a nursing facility or SNF may or may not be treated as the patient’s home for purposes of the higher home administration code for administration of monoclonal antibodies.
Medicare Made Millions of Dollars in Overpayments for End-Stage Renal Disease Monthly Capitation Payments
On May 27, the OIG published a Review of whether CMS made Medicare monthly capitation payments to physicians for monthly ESRD-related services provided in CYs 2016-2018 in accordance with federal requirements. The OIG found that 23,695 claims were for services for which physicians reported monthly ESRD-related billing codes more than once in the same month for the same beneficiary. Of the 23,695 claims with monthly codes reported more than once per month, 21,763 of those claims had different physicians report the monthly codes within the same month, which is not compliant with federal regulations. Overall, the 23,695 noncompliant claims resulted in over $4 million in overpayments. The OIG said CMS lacks the claims processing controls to include system edits which would identify and prevent these overpayments.
The OIG recommends CMS recover the overpayments for claims within the reopening period, instruct physicians to refund $1.1 million in beneficiary cost-sharing related to these claims, review claims which are potentially duplicates, notify physicians to identify and return similar overpayments, and improve claims processing controls--including improved system edits--to prevent and detect overpayments. CMS did not agree with an initial recommendation which had included a reference to physicians as CMS noted the physicians could be found to be without fault under the provisions of the Social Security Act. CMS concurred with the other recommendations.
Spring 2021 Semiannual Report to Congress
On May 28, the OIG published the Spring 2021 Semiannual Report to Congress regarding an overview of OIG activities for October 1, 2020 through March 31, 2021. The OIG said it identified $1.37 billion in expected recoveries and identified $919.97 million in potential savings for HHS during this period. It also highlighted significant actions from the past six months.