This week in Medicare updates—8/15/2018
Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage
On August 7, CMS published a Memo to Medicare Advantage Organization’s to announce the administration’s new policy which will allow Medicare Advantage (MA) plans to use step therapy, a type of prior authorization for drugs that requires patients use the most preferred drug therapy first before moving to more costly therapies if necessary, for Part B drugs beginning January 1, 2019. The move rescinds previous guidance that had prohibited plans from using step therapy practices. CMS is also allowing MA plans that offer a Part D benefit to cross manage the Part B and Part D benefits and will allow these plans to require that patients use a Part D drug therapy before using a Part B drug. CMS said this policy will allow for more competition and negotiation in the market for the drugs and will aid in achieving better deals and lower drug costs for patients.
CMS published a Fact Sheet and Press Release on this policy on the same date.
Medicare Compliance Review of WakeMed Raleigh Campus
On August 8, the OIG published a Review of whether WakeMed Raleigh Campus complied with Medicare requirements for billing inpatient services on selected types of claims. The OIG found that the hospital did not comply with billing requirements for 76 of the 263 claims reviewed during an audit period of September 1, 2014 - August 31, 2016, resulting in net overpayments of $249,954. The errors primarily included incorrectly billed DRG codes and incorrectly billed patient discharge status codes. The OIG recommends that WakeMed refund Medicare for the overpayments for the audit period, identify and return any additional similar overpayments outside of the audit period, and strengthen controls to ensure full compliance with Medicare requirements.
Proposed Rule: Medicare Shared Savings Program; Accountable Care Organizations (ACO)--Pathways to Success
On August 9, CMS published a Proposed Rule for the Medicare Shared Savings Program that would redesign the program by introducing new participation options to encourage ACOs to transition to two-sided models, which have shown significant savings to the Medicare program while improving quality. To accommodate the program’s redesign, CMS is proposing to shift the application cycle by six months in 2019 so that new agreements will begin on July 1, 2019 instead of January 1, 2019, allowing ACOs to have a six-month extension to be able to review the new policies and make informed decisions before applying for a performance year beginning July 1, 2019. CMS would resume the usual application cycle in January 1, 2020.
CMS published a Fact Sheet on the proposed rule on the same date. Comments on the proposed rule are due no later than 5 p.m. on October 16, 2018.
Correction: Medicare Physician Fee Schedule Proposed Rule
On August 9, CMS published a Correction in the Federal Register to replace a figure that was printed incorrectly in the Medicare Physician Fee Schedule proposed rule document published in the Federal Register on July 27, 2018. The figure illustrates the MIPS payment adjustment factors for the 2021 payment year.
Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2016 Average Sales Prices
On August 9, the OIG published a Review of how the price substitution policy impacted Part B drug payments from Q4 2016 - Q3 2017. The OIG found that this policy lowered Part B reimbursement for 16 drugs on the basis of 2016 data, generating $13.1 million in savings over the year. The OIG also determined that CMS and its beneficiaries could have saved up to an additional $2.7 million over one year if CMS implemented a more expansive price-substitution policy, which the OIG recommended doing. CMS did not concur with the recommendation and stated it will consider further changes as additional data becomes available and it gains more experience with price substitution.
Correct the CWF Handling of Beneficiaries with 14+ MSP Occurrences for HETS
On August 10, CMS published One-Time Notification Transmittal 2115 regarding an issue with MSP maintenance transactions inserted into the AUX file within the CWF. A change has been made to the CWF to correct the issue, and a full refresh of all MSP data for all beneficiaries is necessary.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Update of Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2019
On August 10, CMS published Medicare Claims Processing Transmittal 4086 to update the hospice payment rates, wage index, and Pricer, and aggregate cap amount for FY 2019.
Effective date: October 1, 2018
Implementation date: October 1, 2018
International Code of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCD)
On August 10, CMS published One-Time Notification Transmittal 2122 regarding the maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Effective date: January 1, 2019 - Unless otherwise noted in requirements
Implementation date: January 7, 2019 - for shared system edits; September 28, 2018 for local MAC edits
Medicare Diabetes Prevention Program (MDPP) Service Period Change from 3 Years to 2 Years
On August 10, CMS published One-Time Notification Transmittal 2125 to change the MDPP service period in the shared systems and claims processing systems from three years to two years.
Effective date: April 1, 2018
Implementation date: January 7, 2019 - Analysis/Design; April 1, 2019 - Coding/Testing
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2018 Update
On August 10, CMS published Medicare Claims Processing Transmittal 4114 to provide the regular quarterly updates to the HCPCS code set. Beginning on July 12, 2018, the following HCPCS code was established:
- Q5108, injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5mg
Effective date: July 12, 2018
Implementation date: October 1, 2018
Next Generation Accountable Care Organization (ACO) Model 2019 Benefit Enhancement
On August 10, CMS published Demonstrations Transmittal 203 regarding a new benefit for year three of the Next Generation ACO program. This benefit, Care Management Home Visits, will allow Next Generation participants and preferred providers who have initiated a care treatment plan for aligned beneficiaries to be eligible for up to two Care Management Home Visits within 90 days of seeing that participant or preferred provider. Beneficiaries eligible for home health services will not be eligible for this benefit enhancement.
Effective date: January 1, 2019
Implementation date: January 7, 2019
FISS to Add Additional Search Features to Provider Direct Data Entry (DDE) Screen
On August 10, CMS published One-Time Notification Transmittal 2112 to allow providers who use DDE to look up claims associated with a Document Control Number (DCN).
Effective date: January 1, 2019
Implementation date: January 7, 2019
Payments to Home Health Agencies That Do Not Submit Required Quality Data - This CR Rescinds and Fully Replaces CR 9651
On August 10, CMS published Medicare Quality Reporting Incentive Programs 78 to update instructions for the Home Health 2% payment reduction process.
Effective date: August 1, 2018
Implementation date: September 11, 2018
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2018 Update
On August 10, CMS published Medicare Claims Processing Transmittal 4109 regarding the quarterly update to the payment files for the Medicare Physician Fee Schedule.
Effective date: January 1, 2018
Implementation date: October 1, 2018