This week in Medicare updates—9/16/2020

September 16, 2020
Medicare Insider

Provider Specific Fact Sheet Updates

On September 8, CMS updated a number of Provider-Specific Fact Sheets on COVID-19 waivers and flexibilities with information on the resumption of certain demonstration models. Affected fact sheets include:

  • Ambulance
    • CMS revised information to note the resumption of the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization model effective August 3. MACs will conduct postpayment review on RSNAT claims that were paid during the pause without prior authorization.
  • Durable Medical Equipment
    • CMS noted it is resuming full operations for prior authorization of power mobility devices and pressure-reducing support surfaces effective August 3. Prior authorization is also required for certain lower limb prosthetics with dates of service on or after September 1 in the first four states. Prior authorization for those codes will be required in all remaining states effective December 1. 
  • Home Health Agencies
    • CMS is phasing in participation in the Review Choice Demonstration for HHAs in North Carolina and Florida to ease the transition during the PHE. In Illinois, Ohio, and Texas, claims submitted under Choice 1 will not be subject to a 25% payment reduction until further notice.  


New COVID-19 Testing and Reporting Requirements

On September 8, CMS published Slides regarding the new COVID-19 testing and reporting requirements from the IFC published on August 25. In addition to general information, the slides contain tables about testing priorities and frequency as well as lists of resources on testing and lab data reporting.


Updated Civil Monetary Penalties and Affirmative Exclusions

On September 9, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including: 

  • On July 10, RJ Meridian Care Alta Vista, LLC d/b/a Meridian Care Monte Vista, of San Antonio, Texas, reached a $143,630.83 settlement agreement with the OIG to resolve allegations that it employed an individual who was excluded from participating in any federal health care program. 
  • On July 20, Jason Bourque and Allen Research Corporation, of Frisco, Texas, agreed to a 10-year exclusion from federal healthcare programs due to violations of the anti-kickback statute by way of a pain cream payment scheme. 


Updated Provider Self-Disclosure Settlements

On September 10, the OIG published an updated List of Provider Self-Disclosure Settlements with the following organizations:

  • On August 11, VHS San Antonio Partners, LLC, d/b/a St. Luke’s Baptist Hospital, of Texas, reached a $232,200 settlement agreement with the OIG to resolve allegations that it violated the civil monetary penalties law by paying remuneration to two physicians in the form of a disproportionate amount of compensated orthopedic surgery emergency on-call coverage. 

The OIG also reached new settlements with facilities that employed individuals they knew or should have known were excluded from federal healthcare programs, including:

  • Roundup Memorial Healthcare, of Montana
  • Providence Health & Services - Oregon d/b/a Providence Medical Group, of Oregon
  • Providence Health & Services - Oregon, Providence Health Assurance (PHA) and Providence Health Plan, of Oregon
  • Providence Health & Services - Oregon, Providence Portland Medical Center and Providence Office Park, of Oregon
  • St. Vincent Hospital and MetroWest Medical Center, of Massachusetts


Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns

On September 10, the OIG published a Report on whether Medicare Advantage organizations (MAO) are using health risk assessments (HRA) to collect diagnoses that would maximize risk-adjusted payments without improving beneficiary care. The OIG analyzed encounter data from 2016 and found that diagnoses reported only on HRAs and not on any other encounter records resulted in an estimated $2.6 billion in risk-adjusted payments for the audit period. In-home HRAs, which are often conducted by companies that partner with MAOs and therefore are not generally conducted by the beneficiary’s primary care provider, accounted for 80% of these estimated payments. Furthermore, 20 MAOs generated millions in payment from in-home HRAs for beneficiaries who otherwise had no record of any other service being provided during the audit period. The OIG is therefore concerned that MAOs may not be submitting all service records as required, beneficiaries are not receiving follow-up care for concerns identified during HRAs, and inaccurate or unsupported diagnoses are leading to inappropriate risk-adjusted payments. CMS has yet to review the impact of HRAs on risk-adjusted payments or quality of care.

The OIG recommends CMS require MAOs to implement best practices for care coordination, provide targeted oversight of 10 parent organizations driving most of the risk-adjusted payments from in-home HRAs, provide targeted oversight of the 20 MAOs with in-home HRA findings for beneficiaries with no other service records in the encounter data, reassess the risks and benefits of allowing in-home HRAs to be used as sources of diagnoses for risk adjustment, and require MAOs to flag any MAO-initiated HRAs in encounter data. CMS only concurred with the targeted oversight recommendations.


Baylor Scott & White - College Station: Audit of Outpatient Outlier Payments

On September 11, the OIG published a Review of whether outpatient outlier payments received by College Station were based on properly billed claims. The OIG found that College Station improperly billed claims for 82 of the 100 sampled outlier payments, as it found 174 billing errors leading to $474,282 in outliers. These errors were related to overcharged observation time, charge errors, and coding errors. The OIG recommends College Station refund the Medicare contractor in estimated overpayments during the reopening period as well as improve procedures, provide education, and implement changes to the billing system to ensure claims billed to Medicare are accurate. College Station noted it has taken or plans to take a variety of actions to address these issues.


Chapter 15 of Pub. 100-08 Manual Redesign - Additional Release of Chapter 10 of Pub. 100-08, Modification of Timeliness Standards

On September 11, CMS published Medicare Program Integrity Transmittal 10353 regarding the reorganization of manual instructions in chapter 15 and the modification of the timeliness standards for processing all initial and change of information CMS-855 applications, CMS-20134 applications, and opt-out affidavits. 

Effective date: February 1, 2021

Implementation date: February 1, 2021


Chapter 15 of Pub. 100-08 Manual Redesign - Additional Release of Chapter 10

On September 11, CMS published Medicare Program Integrity Transmittal 10345 regarding the reorganization of manual instructions in Chapter 15 (Medicare Enrollment) and movement of the instructions to Chapter 10. This will involve the deletion of approximately 146 sections from Chapter 15 and the creation of 29 new sections in Chapter 10. A crosswalk document is included with the transmittal.

Effective date: November 13, 2020

Implementation date: November 13, 2020


NCD 90.2: Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer

On September 11, CMS published National Coverage Determinations Transmittal 10346 regarding the implementation of new coverage for NGS testing for patients with germline cancer when performed in a CLIA-certified laboratory, ordered by a treating physician, and when specific requirements are met. 

Effective date: January 27, 2020

Implementation date: November 13, 2020


2021 Annual Update of HCPCS Codes for SNF Consolidated Billing (CB) Update

On September 11, CMS published Medicare Claims Processing Transmittal 10349 regarding changes to HCPCS codes for SNF CB. The transmittal states that barring any delay in the Medicare Physician Fee Schedule, the new code files will be provided to the CWF by November 1. It later states that the new code files will be posted to the CMS website by the first week of December. While the MPFS final rule is typically published at the beginning of November, CMS has waived the 60-day delay in effective date this year and is likely to publish the rule later than usual. 

Effective date: January 1, 2021

Implementation date: January 4, 2021


October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

On September 11, CMS published Medicare Claims Processing Transmittal 10348 regarding the October 2020 update to the ASC payment system. Updates include two new cystourethroscopy HCPCS codes, four new skin substitutes effective for October 1, eight new drug/biological codes, and more.

Effective date: October 1, 2020

Implementation date: October 5, 2020