This week in Medicare updates—6/8/2022
New/Modifications to the Place of Service (POS) Codes for Telehealth
On May 27, CMS published Medicare Claims Processing Transmittal 11437, which rescinds and replaces Transmittal 11045, dated October 13, 2021, to adjust the table in the IOM of section 10.5 for POS 32 and 34. The original transmittal was published regarding a new POS code (10) to describe telehealth when health services and health-related services are provided to a patient located in their home via telecommunication technology.
CMS revised MLN Matters 12427 on the same date.
Effective date: January 1, 2022
Implementation date: April 4, 2022
CMS Releases Analysis on 2022 Medicare Part B Premium Reexamination
On May 27, CMS published a Report regarding the reexamination of the 2022 Part B premium in response to the latest developments regarding Aduhelm, a monoclonal antibody directed against amyloid for treating Alzheimer’s disease. For 2022, CMS had factored the potential costs of Aduhelm into the Part B premium, as it was priced at $56,000 at the time and CMS had yet to issue an NCD regarding Aduhelm when setting the premium amounts for Part B. Since that time, CMS completed the NCD for monoclonal antibodies directed against amyloid and determined it would only cover these products under coverage with evidence development. The manufacturer of Aduhelm also lowered the price of the drug to $26,200. In light of these changes, CMS reassessed the Part B premiums and said it now expects the 2023 premium will be lower than the 2022 amount ($170.10). The actual premium amount will be announced in the fall as is customary with the statutory process.
CMS published a Press Release on the same date regarding this report.
OIG Advisory Opinion No. 20-02
On June 1, the OIG published a Modified Advisory Opinion regarding changes to an Advisory Opinion originally published in January 2020. The original opinion was issued regarding whether an arrangement in which a pharmaceutical manufacturer provides financial assistance with travel, lodging, and other expenses for certain patients who have been prescribed the manufacturer’s drug would constitute grounds for sanctions under the civil monetary penalty provisions prohibiting inducements to beneficiaries or in relation to the anti-kickback statute. The requestor is now seeking to modify that arrangement to include the provision of financial assistance to patients for travel, lodging, and other expenses connected with a round trip to an approved treatment center for the cell-removal process associated with the drug.
This drug is a personalized medicine made from the patient’s own cells and is a one-time, potentially curative treatment for a certain type of refractory or relapsed disease. As such, the manufacturer assists eligible patients with travel, lodging, meals, and certain out-of-pocket expenses they incur during the period of time surrounding the infusion when the patients must be close to the administering facility.
The OIG determined that in this case, it would not impose sanctions on the requestor under the anti-kickback statute or beneficiary inducements civil monetary penalties due to a variety of reasons discussed within the opinion.
Advisory Opinion No. 22-12
On June 1, the OIG published an Advisory Opinion regarding whether the OIG would impose sanctions under the federal anti-kickback statute and prohibition on beneficiary inducements civil monetary penalty due to an arrangement in which a Medigap plan would contract with a preferred hospital organization (PHO) and would have network hospitals under the PHO provide discounts to the Medigap plan on policyholders’ Part A inpatient deductibles. The discount would be established in advance and would be applied uniformly to all policyholders for at least one year. The Medigap plan would then offer a $100 premium credit to policyholders who select a network hospital under the PHO for a Part A covered inpatient stay. This credit would apply to the next premium payment due to the policyholder’s Medigap plan after the inpatient stay. The Medigap plan would also pay the PHO a monthly, percentage-based administrative fee to compensate the PHO for establishing the hospital network and arranging for network hospitals to discount the Part A inpatient deductible.
The OIG determined that all three streams of remuneration in this agreement would implicate the anti-kickback statute, and the premium credit from the Medigap plans to the policyholders would implicate the beneficiary inducements civil monetary penalty. However, the OIG said it would not impose sanctions in this case due to a low risk of fraud and abuse. The OIG said several elements of the arrangement factored into its decision, and it discussed these factors in depth in the Opinion.
Medicare Improperly Paid Durable Medical Equipment Suppliers an Estimated $8 Million of the $40 Million Paid for Power Mobility Device (PMD) Repairs
On June 1, the OIG published a Review of whether DME suppliers complied with Medicare requirements when billing for PMD repairs. The OIG found that 261 of the 922 PMD repairs associated with the 100 sampled beneficiaries did not comply with Medicare requirements, as documentation did not adequately support the charges for PMD repairs, the labor time associated with PMD repairs was not documented, or the PMD repair charges were not reasonable and necessary. The OIG estimates that this resulted in $7.9 million in improper payments, and Medicare could have saved an additional $3.7 million for questionably paid PMD repairs.
The OIG recommends CMS instruct the DME contractors to recover the overpayments for PMD repairs, notify suppliers to refund the coinsurance, and notify appropriate suppliers so they can exercise reasonable diligence to identify, report, and return any overpayments. The OIG also made an additional four procedural recommendations detailed in the report. CMS concurred with five of the seven total recommendations.
Comment Request: Complaints Submission Process under the No Surprises Act
On June 2, CMS published a Comment Request in the Federal Register regarding the submission of the following information collection for OMB review:
- Complaints Submission Process under the No Surprises Act
Comments are due to the OMB desk officer by July 5.
Vanderbilt University Medical Center (VUMC): Audit of Outpatient Outlier Payments
On June 2, the OIG published a Review of whether possible billing inconsistencies resulted in improper outpatient outlier payments to VUMC. The OIG found that VUMC did not properly bill claims related to 81 of the reviewed 117 outlier payments. These 81 claims had 110 billing errors resulting in $427,644 in improper outlier payments. Errors primarily occurred because VUMC did not have adequately designed controls or billing system capabilities to prevent coding errors, charge errors, and billing for services not covered by Part B.
The OIG recommends VUMC refund the portion of the outpatient outlier net overpayments for incorrectly billed claims that are within the 4-year reopening period. It also recommends VUMC improve procedures, provide education, and implement changes to its billing system to ensure claims billed to Medicare are accurate.
Updates to Chapters 3, 18, and 32 of the Claims Processing Manual
On June 3, CMS published Medicare Claims Processing Transmittal 11445, which rescinds and replaces Transmittal 11392, dated May 2, 2022, to update Chapter 32 and revise chapter sections and manual content. The original transmittal was published regarding updates to the Inpatient Hospital Billing, Preventive and Screening Services, and Billing Requirements for Special Services chapters of the manual.
Effective date: May 9, 2022 - Unless otherwise specified, it is effective for all dates of service
Implementation date: May 9, 2022 - Unless otherwise specified, it is effective for all dates of service
Medicare Advantage Compliance Audit of Diagnosis Codes that Peoples Health Network Submitted to CMS
On June 3, the OIG published a Review of whether select diagnosis codes that Peoples Health Network, a Medicare Advantage organization, submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by selecting 242 enrollee-years with the high-risk diagnosis codes for which Peoples Health received higher payments for 2015-2016. The OIG found that 144 of the 242 enrollee-years had diagnosis codes that were not supported in the medical records and resulted in $412,938 in overpayments. The OIG estimated that Peoples Health received at least $3.3 million in overpayments for these high-risk diagnosis codes in 2015 and 2016.
The OIG recommended that Peoples Health refund the federal government for the estimated $3.3 million in net overpayments, identify similar instances of noncompliance that occurred outside the audit period and refund any resulting overpayments, and enhance its existing compliance procedures to identify areas where improvements can be made to ensure high-risk diagnosis codes comply with federal requirements. Peoples Health did not concur with any recommendations and said the OIG used flawed audit and extrapolation methodologies, did not evaluate the overall enrollee-year payments or risk scores, and failed to follow CMS’ risk adjustment audit rules. The OIG stands by its original findings.