This week in Medicare updates—8/17/2022
Comment Request: Rehabilitation Unit and Hospital Criteria Worksheet
On August 9, CMS published a Comment Request in the Federal Register regarding the following information collection:
- Rehabilitation Unit and Hospital Criteria Worksheet
Comments are due by October 11.
Suspension of Required Prior Authorization for Certain DMEPOS Items Under Certain Circumstances
On August 10, CMS published a Notice in the Federal Register to announce the suspension of prior authorization for specified orthoses items on the Required Prior Authorization List under certain circumstances when reported with certain modifiers. Items subject to face-to-face encounter and written order prior to delivery requirements are not impacted by this document. This document applies to codes L0648, L0650, L1832, L1833, and L1851 when billed using modifier ST and claims for HCPCS codes L0648, L0650, L1833, and L1851 billed with modifiers KV, J5, or J4 under specific conditions.
Dates: The suspension of the prior authorization requirement took effect on April 13, 2022, when CMS published an announcement on its website.
COVID-19 Monoclonal Antibody Bebtelovimab Made Commercially Available
On August 10, CMS updated its COVID-19 Monoclonal Antibodies webpage to note that, effective August 15, bebtelovimab will be commercially available and the government will not be providing it for free. CMS noted that providers should bill for the product if the batch was purchased commercially. Providers should not bill Medicare for the product if the batch number of the vial is from the government-provided supply. Providers should continue to bill for the administration of the product.
Part D Plan Preference for Higher-Cost Hepatitis C Drugs Led to Higher Medicare and Beneficiary Spending
On August 11, the OIG published a Review of the utilization of hepatitis C drugs in Medicare Part D compared to utilization of the same drugs in Medicaid in 2019 and 2020. The review was conducted because preliminary research indicated that Part D beneficiaries were using higher-cost hepatitis C drugs rather than the generic versions that were increasingly being used by Medicaid beneficiaries. The OIG found that after generic versions of hepatitis C drugs were introduced in 2019, the use of the generic versions increased in Medicaid at a greater rate than they did in Part D. In 2020, some Part D plans did not cover these generic versions of hepatitis C drugs, and Part D beneficiaries without financial assistance paid an average of $2200 more out of pocket for higher-cost hepatitis C drugs. The OIG also found that Medicare spent $155 million more in catastrophic coverage payments for higher-cost hepatitis C drugs than it would had beneficiaries been using the lower-cost generic versions. The results of the review are consistent with suggestions from others that certain Part D programmatic factors, such as manufacturer rebates, may be providing incentives for Part D plans to prefer that their beneficiaries use the higher-cost drugs.
The OIG recommends CMS encourage Part D plans to increase access to generic versions of these drugs. CMS concurred with the OIG recommendations.
Automatic Reprocessing of Claims for Kidney Care Choices (KCC) Model - Implementation
On August 11, CMS published Demonstrations Transmittal 11553 regarding automatic reprocessing of claims for the KCC model. The transmittal reintroduces automatic reprocessing for these claims to avoid multiple issuances of technical direction letters (TDL).
Effective date: January 1, 2023
Implementation date: January 3, 2023
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On August 11, CMS published Medicare Claims Processing Transmittal 11551 regarding the quarterly update to the CLFS. The update includes 23 new proprietary laboratory analysis codes effective October 1, 2022, and one new contractor-priced code.
Effective date: October 1, 2022
Implementation date: October 3, 2022
Significant Updates to Chapter 5 of the Medicare Secondary Payer Manual
On August 12, CMS published Medicare Secondary Payer Transmittal 11550 regarding significant updates throughout Chapter 5 of the manual. The transmittal includes over 200 pages of updated text, with revisions made to out of date verbiage, MSP claims payment examples, and the exclusion of some TDL instructions that were issued to the MACs.
Effective date: October 13, 2022
Implementation date: October 13, 2022