This week in Medicare updates—9/28/2022

September 28, 2022
Medicare Insider

Chronic Care Management Services

On September 19, CMS revised an MLN Booklet regarding chronic care management services. Revisions include changes to billing policies for rural health clinics/federally qualified health centers, the addition of five codes to report staff-provided principal care management services under physician supervision, and the replacement of code G2058 with 99439.


Advisory Opinion No. 22-18

On September 20, the OIG published an Advisory Opinion regarding whether the OIG would impose sanctions under the federal anti-kickback statute and prohibition on beneficiary inducements civil monetary penalty due to an arrangement in which a Medigap plan would contract with a preferred hospital organization (PHO) and would have network hospitals under the PHO provide discounts to the Medigap plan on policyholders’ Part A inpatient deductibles. The discount would be established in advance and would be applied uniformly to all policyholders for at least one year. The Medigap plan would then offer a $100 premium credit to policyholders who select a network hospital under the PHO for a Part A covered inpatient stay. This credit would apply to the next premium payment due to the policyholder’s Medigap plan after the inpatient stay. The Medigap plan would also pay the PHO a monthly, percentage-based administrative fee to compensate the PHO for establishing the hospital network and arranging for network hospitals to discount the Part A inpatient deductible. 

The OIG determined that all three streams of remuneration in this agreement would implicate the anti-kickback statute, and the premium credit from the Medigap plans to the policyholders would implicate the beneficiary inducements civil monetary penalty. However, the OIG said it would not impose sanctions in this case due to a low risk of fraud and abuse. The OIG said several elements of the arrangement factored into its decision, and it discussed these factors in depth in the Opinion.


Medicare Part B Overpaid and Beneficiaries Incurred Cost-Share Overcharges of Over $1 Million for the Same Professional Services

On September 20, the OIG published a Review of whether Part B payments to critical access hospitals (CAH) for professional services and payments made to health care practitioners for the same services complied with federal requirements. The OIG was particularly concerned because prior survey work showed Medicare was paying both CAHs and health care practitioners for the same professional services. The OIG found that of the 40,026 claims reviewed, CAHs and health care practitioners each submitted an equal number of claims but only one claim for each date of service complied with federal requirements. As a result, MACs paid providers $907,438 more than they should have and beneficiaries had to pay $281,321 more than they should have. The OIG attributed the overpayments to CMS’ lack of claim system edits to prevent and detect duplicate professional services claims for the same date of service, beneficiary, and procedure.

The OIG recommends CMS direct the MACs to recover payments from CAHs for which the health care practitioners had not reassigned their billing rights to the CAHs and recover the cost-sharing overcharges for Medicare beneficiaries within the 4-year reopening period, direct MACs to recover the payments from healthcare practitioners for the claims for which the practitioners had reassigned their billing rights to the CAHs and recover the beneficiary cost-sharing overcharges within the 4-year reopening period, and develop system edits or alternative means to prevent and detect overpayments for professional service payments. CMS concurred with all recommendations except the system edits/alternative means to prevent and detect overpayments for these types of services. CMS provided a variety of reasons within the report for not concurring with that recommendation, and the OIG provided suggestions as to how CMS could better monitor this issue.


CMS’ System Edits Significantly Reduced Improper Payments to Acute Care Hospitals After May 2019 for Outpatient Services Provided to Beneficiaries Who Were Inpatients of Other Facilities

On September 23, the OIG published a Review of whether Medicare appropriately paid acute care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities (such as long-term care hospitals, inpatient rehabilitation facilities, etc.). This review was conducted as a follow-up to a previous audit which had found $51.6 million in improper payments for these scenarios. In this audit, the OIG found that Medicare inappropriately paid acute care hospitals $39.3 million for outpatient services provided to beneficiaries who were inpatients of other facilities. However, the vast majority of that total ($32.5 million) was paid before CMS modified system edits to prevent these payments in May 2019. 

The OIG recommends CMS direct the Medicare contractors to recover the portion of the $39.3 million in improper payments within the four-year reopening period, instruct acute care hospitals to refund beneficiaries for deductible and coinsurance amounts that may have been incorrectly collected, direct the contractors to recover any improper payments after the audit period, and continue to review system edits to determine whether any refinements are necessary to prevent future overpayments like these. CMS concurred with all but one recommendation and said it will review data submitted for the audit period to consider how best to address any remaining improper payments made after the audit period.


October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

On September 23, CMS published Medicare Claims Processing Transmittal 11610 regarding the October 2022 update of the ASC payment system. Updates include payment indicator changes for bone (mineral) density studies, a note about device offset payments for CPT code 20950, 10 new HCPCS codes for drugs and biologicals, and more.

Effective date: October 1, 2022

Implementation date: October 3, 2022


FY 2023 Dialysis Facility Outcomes List

On September 23, CMS published a Memorandum to state survey agency directors regarding the annual release of the Dialysis Facility Outcomes List. The list establishes the tier 2 survey workload for state agencies, and it includes the percent of prevalent patients waitlisted (PPPW) measure in its methodology for the first time this year. The memo details the background of the list, discussion about measures, survey considerations, and more.

Effective date: Immediately. Please communicate to all appropriate staff within 30 days.