This week in Medicare updates—7/5/2023

Updated COVID-19 Waivers and Flexibilities Fact Sheets for Providers

On June 26, CMS updated three of the provider-specific COVID-19 waivers and flexibilities fact sheets for:

• Physicians and Other Clinicians 
• Hospitals and CAHs (including Swing Beds, DPUs), ASCs, and CMHCs
• Teaching Hospitals, Teaching Physicians, and Medical Residents

CMS did not specify where these fact sheets were updated, although the hospital fact sheet at one point included a link to data reporting guidance from the NHSN that had been revised on June 11. That link has since disappeared. These fact sheets should therefore be reviewed in their entirety to ensure compliance with all information included within them.

 

Enhancing Oncology Model

On June 27, CMS updated a Fact Sheet, which was originally published in June 2022, regarding a new Innovation Center payment model, the Enhancing Oncology Model (EOM). This nationwide payment model is voluntary and aims to improve care coordination, quality, and health outcomes for patients while holding oncology practices accountable for the total costs of care. The updates list the number of participants in the model as of June 27. This includes 67 oncology physician group practice participants with over 600 sites of care across 37 states. 

The model begins on July 1, 2023, and will have a five-year testing period.

 

Posting of Nursing Home Ownership/Operatorship Affiliation Data on Nursing Home Care Compare Website and Data.CMS.Gov

On June 28, CMS published a Memorandum to state survey agency directors regarding additional nursing home data that will be published on Nursing Home Compare and data.cms.gov. This data includes nursing home affiliation data and aggregate nursing home performance data. This is all part of an ongoing initiative to provide greater transparency about nursing home ownership and quality. 

Data will be posted starting June 28.

 

Corrections to Home Health Processing - Claims with Condition Code DR or Claims Receiving Admission Source Edits

On June 29, CMS published Medicare Claims Processing Transmittal 12106 regarding an update that will require home health claims with condition code DR and occurrence code 50 to include a matching OASIS patient assessment. The update also corrects the processing of home health claims to ensure medical review information isn’t lost when recoding the HIPPS code due to admission source edits. The transmittal also adds instructions to manual secretions about how to avoid delayed submission of a Home Health Notice of Admission. 

CMS published MLN Matters 13225 on the same date to accompany the transmittal.

Effective date: January 1, 2024 - Claims processed on or after this date

Implementation date: January 2, 2024

 

Creation of the Medicare Fee-for-Service (FFS) Companion Guide for 837D (Dental Format)

On June 29, CMS published One-Time Notification Transmittal 12108 regarding instructions to the MACs to use the template attached to the transmittal to create a MAC-specific Companion Guide for the 837D. MACs must adhere to a standard format for this as defined in the CAQH CORE Master Companion Guide for Version 5010.

Effective date: January 1, 2024

Implementation date: September 1, 2023

 

CY 2024 Modifications/Improvements to Value-Based Insurance Design (VBID) Model - Implementation

On June 29, CMS published Demonstrations Transmittal 12111 regarding the implementation of CY 2024 changes into the system for the VBID model’s hospice benefit component. This model is testing the impact on payment and service delivery of incorporating the Part A hospice benefit into the Medicare Advantage benefits package. 

CMS published MLN Matters 13236 on the same date to accompany the transmittal.

Effective date: January 1, 2024

Implementation date: January 2, 2024

 

Proposed Rule: CY 2024 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)

On June 30, CMS published the CY 2024 ESRD PPS Proposed Rule in the Federal Register. Proposals include a payment adjustment that would increase payment for certain new renal dialysis drugs and biological products after the Transitional Drug Add-on Payment Adjustment (TDAPA) period ends. The TDAPA period currently lasts for two years, and this new payment adjustment would be applied for three additional years, would be case-mix adjusted, and would be set at 65% of estimated expenditure levels for the drug or biological from the previous year. Some of the other proposals include:

• Creation of exceptions to the Low-Volume Payment Adjustment (LVPA) attestation process for facilities affected by disasters and other emergencies
• Requirement of reporting “time on machine” data and reporting discarded and unused amounts of certain single-use renal dialysis drugs and biologicals on ESRD PPS claims
• Request for information on potential updates to the LVPA methodology and the potential creation of a new payment adjustment to increase payment to geographically isolated ESRD facilities 

CMS estimates payment updates in the rule will increase ESRD payments for freestanding clinics by 1.6% and increase payments for hospitals by 2.6%. The proposed CY 2024 ESRD PPS base rate is $269.99.

CMS published a Fact Sheet on the proposed rule on the same date. Comments are due by August 25.

 

CMS Releases Revised Guidance for Medicare Drug Price Negotiation Program

On June 30, CMS published Revised Guidance regarding the Medicare Drug Price Negotiation Program in which CMS will negotiate with drug manufacturers to set maximum fair prices for certain high-expenditure, single-source drugs without generic or biosimilar alternatives. After receiving over 7,500 comments on the initial guidance and with multiple lawsuits against the program from drug manufacturers, PhRMA, and the US Chamber of Commerce currently making their way through the court system, CMS has modified some of the original guidance in what it said is an attempt to improve transparency and foster an effective negotiation process. Some of the revisions include:

• Removing a prior secrecy requirement that did not permit drug companies to publicly discuss the negotiations
• Clarifying how CMS will consider negotiation factors such as the consideration of cost-effectiveness measures
• Explaining compliance and oversight activities, such as the engagement of a Medicare Transaction Facilitator to facilitate the exchange of data between supply chain entities to verify the eligibility of maximum fair price-eligible individuals

CMS said it will publish the list of the first 10 drugs included in this program on September 1. CMS published a Press Release and Revised FAQ to accompany the revised guidance.