This week in Medicare updates—8/28/2019
CMS Announces Upcoming Enhancement of Overall Hospital Quality Star Ratings
On August 19, CMS published a Press Release regarding upcoming changes to the quality measurement methodology for the Hospital Quality Star Ratings on Hospital Compare. CMS announced that it plans to update the methodology for the 2021 star ratings via proposed rulemaking that should occur in 2020. In the interim, CMS will refresh the star ratings via the current methodology in 2020. CMS included a link in the press release to a downloadable file containing information on the public comments it received earlier in 2019. CMS will also utilize additional public outreach to help shape proposals to include in future rulemaking on this topic.
Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management
On August 19, CMS published Special Edition MLN Matters 19008 regarding alternative treatment options to consider for patients suffering from chronic pain. The article lists treatments other than opioids that are covered by Medicare under NCDs and LCDs, and it discusses national policies to help care for Medicare beneficiaries with chronic pain. It also suggests potential discussions to have during preventive service visits about opioids and pain management.
Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2017 Average Sales Price
On August 19, OIG published a Review on the impact of the price substitutions when Part B drugs have an average sales price (ASP) greater than 5% of the average manufacturer prices (AMP). When the OIG finds the ASP exceeds the AMP by this margin, it directs HHS to substitute the ASP-based payment amount with a lower calculated rate. In 2017, CMS applied this price substitution policy to 14 drugs, which resulted in $7 million in savings for that year. CMS currently uses a duration criteria for this policy where the ASP must exceed the AMP for a certain amount of quarters in a year in order for CMS to apply the price substitution. However, the OIG found that if CMS applied this policy to drugs whose ASP exceeded the AMP by 5% in a single quarter, CMS could have saved an additional $2.9 million. The OIG therefore recommends CMS expand its price substitution criteria. CMS did not concur with the recommendation but said it will consider further changes once additional data becomes available and it become more familiar with the price substitution policy.
Comment Request: Advance Beneficiary Notice of Noncoverage (ABN)
On August 20, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Advance Beneficiary Notice of Noncoverage (ABN).” Comments are due October 21, 2019.
2018 Report to Congress: Review of Medicare’s Program Oversight of Accrediting Organizations (AO) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program
On August 20, CMS published a Memorandum to state survey agency directors regarding the 2018 Report to Congress detailing the review, validation, and oversight of the 2017 activities of approved AOs for Medicare accreditation programs and the CLIA Validation Program. The memorandum contains a full copy of that report.
New Documentation Requirements for Filing Medicare Cost Reports
On August 21, CMS published Special Edition MLN Matters 19015 regarding new documentation requirements for Medicare cost reports that were finalized in the FY 2019 IPPS final rule. The article identifies reasons cost reports would be rejected under the new documentation requirements as they apply to organizations or situations such as teaching hospitals, bad debt, DSH-eligible hospitals, charity care and uninsured discounts, and home office cost allocations.
Review of MAC Information Security Program Evaluations for FY 2018
On August 23, the OIG published a Review assessing the scope and sufficiency of MAC information security program evaluations. The OIG found that these programs were adequate in scope and sufficiency even though there were a total of 112 gaps at seven MACs for FY 2018, which represents a 26% increase in gaps for those same seven contractors from 2017. The OIG attributed this rise in part due to the addition of database and web server testing. It stated in the review that CMS should continue its oversight visits and ensure that MACs remediate all gaps, but the OIG did not have any official recommendations in the report.
New York Should Improve Its Oversight of Selected Nursing Homes’ Compliance with Federal Requirements for Life Safety and Emergency Preparedness
On August 23, the OIG published a Review of whether New York state ensured that selected nursing homes in the state that participate in Medicare or Medicaid complied with CMS requirements for life safety and emergency preparedness. The OIG found that the state did not ensure that selected nursing homes complied with CMS requirements for life safety and emergency preparedness, as it found deficiencies in these areas at all 20 nursing homes surveyed in this review. It found issues with life safety requirements related to fire detection and suppression systems, carbon monoxide detectors, hazardous storage, elevator and equipment testing, and more. Issues with emergency preparedness requirements included noncompliance with written emergency plans, tracking residents and staff, emergency plan training, and more. The OIG attributed these issues to inadequate management oversight and staff turnover at these nursing homes. It also noted that New York did not have a standard life safety training program for all nursing home staff, generally performed life safety surveys no more frequently than once every 9-15 months, and did not check to see whether carbon monoxide detectors were installed.
The OIG issued a series of recommendations to the state of New York, which the state generally agreed with, but New York objected to the timing, audit objective, sampling methodology, qualifications of the audit team, and some of the findings. The OIG modified one recommendation due to the state’s response.
2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
On August 23, CMS published Medicare Claims Processing Transmittal 4379 regarding the annual files for automated payments of HPSA bonus payments. The file should be used for automated bonus payments for claims with dates of service on or after January 1, 2020, through December 31, 2020.
CMS published MLN Matters 11437 on the same date to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Home Health Patient-Driven Groupings Model (PDGM) - Revised and Additional Manual Instructions
On August 23, CMS published Medicare Claims Processing Transmittal 4378 regarding revisions to the manual to support the implementation of PDGM and to create new sections to describe the PDGM Grouper program. These changes apply to a section in Chapter 10 of the manual about changes in a beneficiary’s payment source as well as a section on the Grouper program, its input/output record layout, and its decision logic and updates.
CMS published MLN Matters 11395 on the same date to accompany the transmittal.
Effective date: January 1, 2020 - Claim “From” dates on or after this date.
Implementation date: November 27, 2019
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE
On August 23, CMS published Medicare Claims Processing Transmittal 4376 regarding instructions to the shared system maintainers (SSM) to update systems based on the CORE 360 Uniform use of CARC, RARC, and CAGC rule publication.
CMS published MLN Matters 11394 on the same date to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Claim Status Category and Claim Status Codes Update
On August 23, CMS published Medicare Claims Processing Transmittal 4377 regarding the regular update of the claim status and claim status category codes used for the ASC X12 276/277 Health Care Claim Status Request and Response and the ASC X12 277 Health Care Claim Acknowledgement transactions.
CMS published MLN Matters 11393 on the same date to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code Set Update
On August 23, CMS published Medicare Claims Processing Transmittal 4371 regarding the October update to the HPTCs.
CMS published MLN Matters 11418 on the same date to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020 - Contractors with the capability to do so shall implement this CR effective October 1, 2019.
2020 HCPCS Annual Update Reminder
On August 23, CMS published Medicare Claims Processing Transmittal 4374 as a reminder that the annual update of the 2020 HCPCS codes will be available for download via the CMS mainframe in early November.
Effective date: January 1, 2020
Implementation date: January 6, 2020