This week in Medicare updates—7/10/2019

Extension of Enforcement Discretion Period for Laboratory Date of Service Exception Policy

On June 28, CMS published an announcement and Q&A file as a download on its Laboratory Date of Service Policy webpage to announce it will exercise enforcement discretion of the laboratory date of service (DOS) exception policy under the Clinical Laboratory Fee Schedule (CLFS) for another six months. This extension will last until January 2, 2020. In the FAQs, CMS stated that hospitals and laboratories who are prepared to comply with the new lab DOS exception policy should do so, but those that are not ready should make every effort to be ready by January 2, 2020.

 

Medicare DMEPOS Improper Inpatient Payments

On July 1, CMS published an MLN Fact Sheet regarding proper billing and payment policies for inpatient durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). All DMEPOS items are included during a Part A covered stay in the inpatient PPS rate and may not be billed separately. The fact sheet discusses current policy, details conditions for delivery of DMEPOS items before discharge, and provides a resource table with links to relevant guidance on DMEPOS billing and payments.

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On July 1, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following: 

• On May 6, Park Royal Hospital, of Fort Myers, Florida, reached a $52,414 settlement agreement with the OIG to resolve allegations that it violated EMTALA by failing to accept a transfer of a patient from the ED of another hospital following a suicide attempt. Park Hospital refused to accept the transfer despite having the capacity and the specialized capabilities to stabilize the patient because the patient’s insurance was out of network. 
• On May 20, Paul S. Moniz, D.O., Guy D. Roberts, D.O., and Midwest Health Group, LLC, of Farmington Missouri, reached a $96,880 settlement agreement with the OIG to resolve allegations that it received remuneration from Health Diagnostic Laboratory, Inc., in the form of “process and handling payments” related to the collection of blood. 
• On May 21, Yousef Mehrabi, M.D., of Encino, California, reached a $52,799.61 settlement agreement with the OIG to resolve allegations that it submitted claims for nerve conduction studies that are not covered by Medicare because they are considered screening exams. 
• On May 22, On-Site Imaging, LLC, of Morganville, New Jersey, reached a $82,065.08 settlement agreement with the OIG to resolve allegations that it submitted claims for HCPCS code 96965 when those claims were for a procedure already included as a component of the duplex ultrasound procedures that On-Site had already submitted claims for under HCPCS code 93970 or 93971 for the same beneficiary on the same dates of service. The claims for HCPCS code 96965 were for a procedure that should not have been separately billed and was not medically necessary. 
• On May 28, Ryan D. Pensyl, DMD, of Cumberland, Maryland, reached a $10,941.60 settlement agreement with the OIG to resolve allegations that Dr. Pensyl employed an individual who was excluded from participating in any federal health care program. 
• On May 31, Commonwealth Pain Associates, PLLC, of Louisville, Kentucky, reached an $88,214.88 settlement agreement with the OIG to resolve allegations that Commonwealth submitted claims to Medicare for specimen validity testing, which is a non-covered service.
• On June 26, Transylvania Regional Hospital, MH Transylvania Regional Hospital, LLLP, and Transylvania Community Hospital, Inc., of Brevard, North Carolina, reached a $25,000 settlement agreement with the OIG to resolve allegations that it violated EMTALA by failing to provide an adequate medical screening examination and stabilizing treatment for a patient with abdominal pain and pain radiating bilaterally to his lower extremities. The patient returned the same day via ambulance and was ultimately transferred to another hospital.

 

Reduce Risk of Opioid Overdose Deaths by Avoiding and Reducing Co-Prescribing Benzodiazepines

On July 1, CMS published Special Edition MLN Matters 19011 regarding prescriptions for opioids and benzodiazepines. The article details five central practices providers can adopt to avoid co-prescribing benzodiazepines and opioids, as concurrent use of these drugs presents multiple potential risks for prescribers and people with chronic pain.

 

FAQs on the Emergency Medical Treatment and Labor Act (EMTALA) and Psychiatric Hospitals

On July 2, CMS published a Memorandum to state survey agency directors regarding psychiatric hospital compliance with EMTALA. Medicare-participating psychiatric hospitals are required to comply with EMTALA, and CMS provided an FAQ to address common inquiries from these hospitals about the EMTALA requirements. 

Effective date: Immediately. The FAQ should be shared with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of the memorandum.

 

Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM)

On July 2, CMS published a Decision Memo regarding an update to an NCD which expands coverage of ABPM to include beneficiaries with suspected masked hypertension, which occurs when blood pressure readings during an office visit are lower than they may be out of the office. The decision also lowers the blood pressure threshold for hypertension from 140/90 down to 130/80, which will make ABPM available to more patients who may benefit from treatment. 

CMS published a Press Release on the same date to accompany the decision memo.

 

Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program

On July 3, CMS published Medicare Claims Processing Transmittal 4332, which rescinds and replaces Transmittal 4290, dated May 3, 2019, to revise the background section to remove reference to rejections for FISS. The original transmittal was issued regarding modifications to claims processing systems to ensure that MSNs appropriately differentiate between QMB claims that are paid and denied. 

Effective date: October 1, 2019

Implementation date: October 7, 2019 - For claims processed on or after this date

 

Updated Provider Self-Disclosure Settlements

On July 3, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

• On June 28, Five Star Quality Care-CA, LLC d/b/a Van Nuys Healthcare Center (VNHC), of California, reached a $1,138,807.29 settlement with the OIG to resolve allegations that its Director of Nursing and Minimum Data Set (MDS) Coordinator reported false assessment reference dates on MDS reports required by Medicare. 

The list also includes four settlements reached after facilities self-disclosed that they employed individuals they knew or should have known were excluded from participation in federal health care programs. These facilities include: 

• Community Health Centers, of Vermont
• LifeSkills, Inc., of Kentucky
• Shands Teaching Hospital and Clinics, Inc., d/b/a UF Health Shands, of Florida
• Total Health Care, Inc., of Maryland

 

Medicare Part D Rebates for Prescriptions Filled at 340B Contract Pharmacies

On July 5, the OIG published a Review of what the rebate amount could have been had pharmaceutical manufacturers and Part D sponsors agreed that prescriptions for Part D beneficiaries filled at 340B contract pharmacies would generate rebates for those sponsors. The OIG determined that tens of millions of dollars in rebates could have been generated if manufacturers and sponsors had agreed that eligible prescriptions filled at 340B contract pharmacies would receive rebates. This is based on a calculation which determined that these Part D prescriptions filled at non-340B pharmacies would have generated $74.7 million in rebates in 2014. The OIG therefore determined that there is an opportunity to reduce Part D costs if sponsors were to negotiate similar net prices for both non-340B drugs dispensed by 340B contract pharmacies and drugs dispensed by non-340B pharmacies. The report contains no recommendations, as it is intended to inform congressional and administration decision-makers of the impact that drugs dispensed at 340B contract pharmacies may have on the Part D program.

 

Implementation to Send Pre-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System

On July 5, CMS published One-Time Notification Transmittal 2319, which rescinds and replaces Transmittal 2302, dated May 10, 2019, to revise business requirement 11141.1.1.3, the note in business requirement 11141.1.1.2, and the file layout attachment (eMDR Pre-Pay Data Elements). The original transmittal was issued regarding implementation of files and changes that will support sending ADR letters electronically as Pre-Pay eMDRs.

Effective date: January 1, 2020

Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation

 

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - October 2019

On July 5, CMS published Medicare Claims Processing Transmittal 4329 regarding the quarterly update to the DME CBP files in order to implement changes to HCPCS codes, zip codes, single payment amounts, and supplier files. 

Effective date: October 1, 2019

Implementation date: October 7, 2019

 

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019

On July 5, CMS published Medicare Claims Processing Transmittal 4330 regarding the October quarterly update of the NCD edit module for clinical diagnostic laboratory services. 

Effective date: October 1, 2019

Implementation date: October 7, 2019

 

October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

On July 5, CMS published Medicare Claims Processing Transmittal 4331 regarding the quarterly drug pricing files for ASP and Not Otherwise Classified drugs. 

Effective date: October 1, 2019

Implementation date: October 7, 2019