This week in Medicare updates—7/11/2018

July 11, 2018
Medicare Insider

2019 Home Health Prospective Payment System Proposed Rule

On July 2, CMS published the display copy of the 2019 Home Health Prospective Payment System Proposed Rule, which is scheduled to be published in the Federal Register on July 12. The rule proposes increasing the payment rate to home health agencies (HHA) by 2.1% for CY 2019. It also contains significant modifications as required by the Bipartisan Budget Act of 2018 to implement the Patient-Driven Groupings Model (PDGM) for home health payments, which would eliminate the use of therapy thresholds in determining payment and change the unit of payment to 30-day periods of care (to be implemented in a budget-neutral manner as of January 1, 2020).

The rule also includes a proposal to allow the cost of remote patient monitoring to be reported by HHAs as allowable costs on the cost report form and contains information on the implementation of home infusion therapy temporary transitional payments, which is another requirement from the Bipartisan Budget Act of 2018.

CMS published a Press Release and Fact Sheet to accompany the proposed rule. Comments on the rule are due by 5 p.m. on August 31, 2018.  


Comment Request: Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

On July 3, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration.” Comments are due by September 4, 2018.


2018 Medicare Shared Savings Program and Merit-based Incentive Payment System (MIPS) Interactions

On July 3, CMS published a Table to display the interactions between the Medicare Shared Savings Program and MIPS for 2018. The table outlines how accountable care organizations (ACO) with different statuses are scored in each of the four MIPS performance categories, what level of reporting is required for each category, how the low volume threshold is determined for each ACO status, and whether that ACO status would make participants eligible for the MIPS APM scoring standard.


Promoting Interoperability Infographic

On July 5, CMS published an Infographic regarding the name change for the Promoting Interoperability performance category in the MIPS pathway. The performance category was formerly known as the Advancing Care Information performance category. The infographic illustrates how the performance category differs from the Promoting Interoperability Programs (formerly known as the EHR Incentive Programs) and contains links to downloadable information on both the performance category and Promoting Interoperability Programs.


New Medicare Card: MBI Changes

On July 5, CMS published an Announcement in the weekly MLN Connects newsletter to explain situations in which a Medicare Beneficiary Identifier (MBI) may change and when providers should use the old or new MBIs. CMS is continuing to mail new Medicare cards but has finished mailing cards to most people in states included in Wave 1 of the mailings (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia).


Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2018 Update

On July 5, CMS published Medicare Claims Processing Transmittal 4083, which rescinds and replaces Transmittal 4078, dated June 26, 2018, to revise the type of service (TOS) information for CPT code 90739 in the background section and in business requirement 10624.5. The original transmittal was issued regarding the quarterly updates to drug/biological HCPCS codes.

On July 6, CMS published a revised MLN Matters 10624 to accompany the transmittal.

Effective date: July 1, 2018

Implementation date: July 2, 2018


Clarify Detailed Written Orders for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

On July 6, CMS published Medicare Program Integrity Transmittal 806 to clarify the instructions for conducting medical reviews of written orders provided for most items of DMEPOS. Detailed written orders were previously required to have a start date, but now the orders are required to contain the date that the order was written. The transmittal also clarifies items which require a written order prior to delivery to include 42 CFR 410.38(d).

Effective date: August 7, 2018

Implementation date: August 7, 2018


Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2019

On July 6, CMS published Medicare Claims Processing Transmittal 4084 regarding updates to the payment rates used under the SNF PPS for FY 2019. The FY 2019 SNF payment increase factor is 2.4% as required by the Bipartisan Budget Act of 2018.

Effective date: October 1, 2018

Implementation date: October 1, 2018


Revisions to the State Operations Manual (SOM) Chapter Two for Organ Procurement Organizations (OPOs)

On July 6, CMS published State Operations Provider Certification Transmittal 179 regarding significant revisions to Chapter 2 of the SOM on OPOs. The changes include revisions to instructions on opening an OPO Donation Service Area (DSA) for competition, OPO application reviews, the OPO selection process, the OPO transition process, and instructions on what to do if no OPO applies for an open DSA.

Effective date: July 6, 2018

Implementation date: July 6, 2018


New Provider Self-Disclosure Settlements

On July 6, the OIG updated its list of Provider Self-Disclosure Settlements reached in June. The list includes:

  • On June 8, LSU Health Sciences Center Shreveport, of Louisiana, reached a $732,854.40 settlement after allegedly submitting claims for physician services by teaching surgeons when those services were supervisory services to the hospital rather than a physician service to individual patients.
  • On June 11, Magee Benevolent Association d/b/a Magee General Hospital, of Mississippi, reached a $10,000 settlement after allegedly providing remuneration to physicians and physician practices in the form of office space, transcription services, and/or personnel services at rates below fair market value. The OIG alleged that remuneration created financial relationships and Magee presented claims for designated health services resulting from the prohibited referrals.
  • On June 25, Steward Medical Group, of Massachusetts, reached a $196,677 settlement after allegedly presenting improper claims to federal healthcare programs for physician office visits by established patients of an employed physician and improper claims for intraoperative ultrasounds during partial nephrectomies under CPT code 76998-26 which were not supported by accurate medical record documentation.
  • On June 26, United Family Practice Health Center, of Minnesota, reached a $518,710 settlement after allegedly submitting claims for reimbursement for services to Medicare patients under HCPCS codes G0402, G0438, and G0439 that were not properly supported by documentation in the medical record.  

The list also included five organizations who reached settlements after allegedly employing individuals the organizations knew or should have known were excluded from participation in federal healthcare programs. These organizations include:

  • Adventist Health System Sunbelt Healthcare Corporation, of Florida
  • Joint Implant Surgeons, Inc., of Ohio
  • Tremont Rehabilitation and Skilled Care Center, of Massachusetts
  • NorthStar Services, of Nebraska
  • Schryver Medical, LLC, of Colorado


University of Wisconsin Hospitals and Clinics Authority Incorrectly Billed Medicare Inpatient Claims with Severe Malnutrition

On July 6, the OIG published a Report regarding whether the University of Wisconsin Hospitals and Clinics Authority complied with Medicare billing requirements when billing for Nutritional Marasmus and other/unspecified severe protein-calorie malnutrition. The OIG found that the hospital failed to comply with billing requirements in 90 of the 100 sample claims reviewed by the OIG. For 88 of those claims, the errors occurred because the hospital used severe malnutrition diagnosis codes when it should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all, as the medical record documentation for these claims did not support the severe malnutrition code or did not provide evidence that the malnutrition had an effect on the treatment or length of the hospital stay. The OIG estimated that, as a result, the hospital received overpayments of at least $2,412,137 during the audit period.

The OIG recommends that the hospital refunds the Medicare for the total amount of overpayments, exercises diligence to identify and return any additional similar overpayments outside of the audit period, and strengthen controls to ensure full compliance. The hospital partially disagreed with the first recommendation and disagreed with the other two recommendations for reasons explained in the OIG report.


Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)

On July 6, CMS revised a Memorandum to state survey agency directions regarding CMS expectations for healthcare facilities to have water management policies and procedures that would reduce the risk of the growth and spread of Legionella in building water systems. CMS revised the memo to clarify the expectations for providers, accrediting organizations, and surveyors regarding these policies and procedures. CMS stated that this memo primarily applies to hospitals, critical access hospitals, and long-term care facilities, and CMS listed new contacts in the memo for each type of facility should providers have any questions or concerns about the memorandum.

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

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