This week in Medicare updates—7/27/2022
Renewal of COVID-19 PHE
On July 15, ASPR published a Notice announcing that the COVID-19 PHE has been extended effective July 15, 2022. This will extend the PHE and all applicable waivers tied to it for an additional 90 days.
Audits of Nursing Home Life Safety and Emergency Preparedness Identified Noncompliance, Opportunities
On July 18, the OIG published a Report on state compliance with CMS’ life safety and emergency preparedness requirements for nursing homes. It also aimed to identify opportunities for CMS to improve resident, visitor, and staff safety. The OIG found a total of 2,233 areas of noncompliance with life safety and emergency preparedness requirements at 150 of the 154 nursing homes visited across eight states. The OIG identified several factors for these issues, such as inadequate oversight by management and state survey agencies, staff turnover, and a lack of any requirement for mandatory participation in standardized life safety training programs. The OIG highlighted a variety of opportunities for CMS to expand on its life safety requirements for nursing homes to improve the safety of residents, visitors, and staff.
The OIG recommends CMS propose regulations requiring nursing homes to install carbon monoxide detectors, propose regulations requiring nursing homes and inspection contractors to notify state survey agencies when fire alarm and sprinkler systems are not working or may be in jeopardy of not working, work with states to encourage mandatory participation in standardized training for nursing home staff, and develop a plan in conjunction with state survey agencies to address the foundational issues preventing more frequent surveys at nursing homes with a history of multiple high-risk deficiencies. CMS generally agreed with the recommendations.
Updated OIG Work Plan
On July 18, the OIG updated its Work Plan with the following new items:
- Congressional Mandate: Noncovered Versions of Part B Drugs
- Opioid Use in Medicare Part D in 2021: Annual Review
- Medicare Payments for Intermittent Urinary Catheters
Special Fraud Alert: OIG Alerts Practitioners to Exercise Caution When Entering Into Arrangements With Purported Telemedicine Companies
On July 20, the OIG published a Special Fraud Alert warning about an increase in fraud schemes involving telemedicine companies. The alert includes information on common elements of these schemes, describes which federal laws are implicated in arrangements with these companies, discusses recent enforcement activities, and notes suspect characteristics for practitioners to watch out for when entering into arrangements with these companies.
The OIG also linked to a number of resources it has published recently on telehealth and potential fraud schemes.
FDA Grants EUA for Novavax COVID-19 Vaccine
On July 20, CMS updated the COVID-19 Vaccine and Monoclonal Antibody webpage regarding the Novavax COVID-19 vaccine, which was granted an EUA by the FDA on July 13 for use in patients 18 years or older. Providers should report CPT code 0041A for the first dose of the Novavax vaccine and CPT code 0042A for the second dose of the vaccine. The vaccine will be reported with CPT code 91304. Those codes are effective July 13, 2022. As with other vaccines, payment rates for each dose will be $40.
Medicare Critical Care Services Provider Compliance Audit: Lahey Clinic, Inc.
On July 21, the OIG published a Review of whether Lahey Clinic, Inc., complied with Medicare requirements when billing for critical care services performed by its physicians. The OIG found that Lahey did not comply with Medicare billing requirements for 56 of the 92 critical care services reviewed. It said 54 of the critical care services billed were for patients whose conditions did not indicate that critical care services were necessary or for which the physician did not directly provide services at the level of care required for critical care services. The OIG also found two critical care services which were billed using an incorrect CPT code. The OIG estimated that as a result of these errors, Lahey received $6,015 in unallowable Medicare payments.
The OIG recommended Lahey refund the MAC for the $6,015 in overpayments, and it made procedural recommendations for Lahey to strengthen its policies and procedures. Lahey concurred with the findings for 16 of the 56 services found to be in error, but it stated that the remaining 40 critical care services were justified. The OIG said that Lahey did not provide any additional medical record documentation to support its arguments for those 40 services and therefore it maintained its original findings.
Corrections to Processing of Canceled Home Health Notices of Admission and of Period Sequence Edits
On July 21, CMS published One-Time Notification Transmittal 11503 regarding modifications to the Medicare systems to ensure prior periods are updated correctly when a Notice of Admission is canceled. It also ensures medical review information is not removed when claims are subsequently adjusted due to period sequence edits.
Effective date: January 1, 2023 - Claims processed on or after this date
Implementation date: January 3, 2023
Modification of Existing Common Working File (CWF) Editing for Preventive Services
On July 21, CMS published Medicare Claims Processing Transmittal 11504 regarding modifications to the CWF to allow frequency limitation editing to be overridden by contractors. CMS is making this change because when claims are paid outside of the CWF, the claim history does not get updated in the CWF, which leads to incorrect information about the last date the service was covered. CMS is modifying the CWF to avoid this issue.
Effective date: January 1, 2023
Implementation date: January 3, 2023