This week in Medicare updates—8/29/18

August 29, 2018
Medicare Insider

Medicare Made Improper and Potentially Improper Payments for Emergency Ambulance Transports to Destinations Other Than Hospitals or Skilled Nursing Facilities

On August 20, the OIG published a Review of whether Medicare payments for emergency ambulance transports to destinations other than hospitals or skilled nursing facilities complied with federal requirements. The OIG found that Medicare made improper payments of $975,154 for transports to destinations not covered by Medicare for either emergency or nonemergency ambulance transports, and Medicare made potentially improper payments of $928,092 for transports that may not have met Medicare coverage or may have been paid by Medicare as nonemergency ambulance transports. The OIG recommends CMS recover the $975,154 in improper payments within the 4-year claim reopening period and review claim lines in that period for transports that may have been improperly paid under the $928,092 in potentially improper payments.


Medicare Improperly Paid Hospitals Millions of Dollars for Intensity-Modulated Radiation Therapy (IMRT) Planning Services

On August 20, the OIG published a Review of whether payments for outpatient IMRT planning services complied with Medicare billing requirements. The OIG found that all 100 line items in the sample were improperly paid, resulting in an estimated $25.8 million in overpayments to hospitals. The OIG discovered that hospitals separately billed for complex simulations under CPT code 77290 when these services were performed as part of IMRT planning, but that code should have been bundled into payment under CPT code 77301 regardless of whether the codes were reported on the same date of service. However, the NCCI edits in place to prevent separate payments for codes 77290 and 77301 did not prevent overpayments when these services were reported on different dates of service. Hospitals also appeared to be unfamiliar with or misinterpreted CMS guidance on billing these services.

The OIG recommends CMS implement an edit to prevent improper payments for IMRT planning services that are billed before the procedure code for the bundled payment for IMRT planning is billed. The OIG also recommends CMS work with Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.


2018 Merit-based Incentive Payment System (MIPS) Quality Performance Category: Claims Data Submission Fact Sheet

On August 21, CMS published a Fact Sheet on how to submit data for the Quality performance category in MIPS by using claims. The fact sheet reviews the five steps involved in submitting data via this method, discusses the Quality Data Codes verification methods, and provides additional tips for successful participation in MIPS via claims data submission.


Liberty Medical, LLC, Received Unallowable Medicare Payments for Inhalation Drugs

On August 21, the OIG published a Review of whether Liberty Medical, LLC, complied with Medicare requirements when billing for inhalation drugs. The OIG found that, for six of the 100 sampled claim lines, Liberty did not comply with Medicare requirements due to a lack of medical records for four claim lines and inadequate proof-of-delivery documentation for two claim lines. As a result, Liberty received $2,408 in unallowable Medicare payments during the audit period of CY 2015 - 2016. The OIG estimates that Liberty has received at least $47,526 in unallowable Medicare payments based on this sample.

The OIG recommends Liberty refund the $47,526 in estimated overpayments to the Medicare contractors, exercise reasonable diligence to identify and return any similar overpayments, strengthen its policies and procedures to ensure it can provide medical records for inhalation drugs when requested, and improve its order processing system to maintain adequate proof-of-delivery documentation.


Advisory Opinion 18-09

On August 21, the OIG published an Advisory Opinion on the use of a “preferred hospital” network as part of a Medigap policy whereby an insurance company would contract indirectly with hospitals for discounts on Medicare inpatient deductibles for its policyholders, and it would then provide a premium credit of $100 off the next renewal premium to policyholders who use a network hospital for an inpatient stay. The requestor asked whether this arrangement would constitute grounds for the imposition of sanctions under the anti-kickback statute or civil monetary penalties law. The OIG determined that, although the arrangement could potentially generate prohibited remuneration under the anti-kickback statute and civil monetary penalties law, the OIG would not impose administrative sanctions in this case due to reasons detailed within the report.   


Updated Civil Monetary Penalties and Affirmative Exclusions

On August 23, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusion agreements a new exclusion agreement, including:

  • On August 8, CHJ Diagnostic, Inc., of Orange, California, and its owner, Andranik Tovmasyan, agreed to be excluded for a period of five years after the OIG found that CHJ submitted claims for nerve conduction studies that are considered screening exams not covered by Medicare.


OIG Excludes Company and Owner from Federal Healthcare Programs

On August 23, the OIG published an Announcement of a decision by Administrative Law Judge Bill Thomas to uphold the OIG’s 15-year exclusion of Karim Maghareh, PH.D., and BestCare Laboratory Services, LLC, from participation in all federal healthcare programs. Maghareh and BestCare were found to have submitted false claims to Medicare for reimbursement of travel costs associated with the collection of samples on which BestCare performed laboratory tests.


Chimeric Antigen Receptor (CAR) T-Cell Therapy and Patient Reported Outcomes Scoresheet

On August 23, CMS posted the Scoresheet from the August 22 MEDCAC meeting regarding CAR T-Cell Therapy and Patient Reported Outcomes. The scoresheet reflects the voting tallies from the five major questions posed at the meeting.


Certain Changes to the Low-Volume Hospital Payment Adjustment Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for Fiscal Years 2011 Through 2017

On August 21, CMS published an Application of a Payment Adjustment in the Federal Register to announce changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.

Effective date: August 22, 2018

Applicability date: The provisions described in this document are applicable for discharges on or after October 1, 2010, and on or before September 30, 2017, in accordance with section 429 of the Consolidated Appropriations Act, 2018.


Updated Corporate Integrity Agreement Documents

On August 23, the OIG published information on three new Corporate Integrity Agreements. These include:


Update to Chapter 15 of Publication 100-08, Certification Statement Policies

On August 24, CMS published Medicare Program Integrity Transmittal 822 regarding modifications to certain provider enrollment certification statement policies that will allow these statements to be uploaded into the Provider Enrollment Chain and Ownership System (PECOS).

Effective date: October 1, 2018

Implementation date: October 1, 2018


October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)

On August 24, CMS published Medicare Claims Processing Transmittal 4123 regarding changes to and billing instructions for various payment policies implemented in the October 2018 OPPS update. The October 2018 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS modifier, and Revenue Code additions, changes, and deletions identified within the transmittal.

Effective date: October 1, 2018

Implementation date: October 1, 2018


October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3

On August 24, CMS published Medicare Claims Processing Transmittal 4122 to provide the I/OCE instructions and specifications that will be used under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for treatment of a non-terminal illness.

Effective date: October 1, 2018

Implementation date: October 1, 2018