This week in Medicare updates—9/29/2021

Medicare Clarifies Recognition of Interstate License Compacts

On September 16, CMS revised Special Edition MLN Matters 20008, originally published May 5, 2020, to clarify language about licenses certain providers get through interstate licensing compact pathways. The original article was published regarding licensure requirements for physicians and non-physician practitioners covered by interstate licensing compacts who wish to bill MACs for services.

 

CMS Launches New Medicare.gov Tool to Compare Nursing Home Vaccination Rates

On September 21, CMS published a Press Release announcing that it is creating a tool on the Medicare website that will make vaccination data for nursing homes available in a user-friendly format. This tool is intended both to help people make informed decisions when choosing a nursing home and as a way for CMS and the CDC to monitor vaccine uptake among residents and staff and to identify facilities that may need additional resources or assistance. 

 

ETC Managing Clinician PPA and KCF PBA Implementation

On September 21, CMS published Demonstrations Transmittal 11017, which rescinds and replaces Transmittal 10960, dated August 18, 2021, to revise business requirement 12404.30 and to add the NHC to business requirements 12404.25 and 12404.28. The original transmittal was published regarding implementation of payment adjustments for the ESRD Treatment Choices (ETC) Model and the Kidney Care Choices (KCC) Model. 

Effective date: January 1, 2022

Implementation date: January 3, 2022 - Implement all BRs related to ETC Managing Clinician Performance Payment Adjustment (PPA); April 4, 2022 - Implement all BRs related to KCF Performance Based Adjustment (PBA)

 

Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments to Disproportionately Drive Payments

On September 22, the OIG published a Review of whether Medicare Advantage (MA) companies leverage chart reviews and health risk assessments (HRA) to maximize risk adjusted payments without beneficiaries receiving care for those diagnoses. While chart reviews and HRAs are allowable sources of diagnoses for risk adjustment, the way CMS risk-adjusts payments by using beneficiary diagnoses may create an incentive for MA companies to make beneficiaries appear as sick as possible. The OIG found that 20 of the 160 MA companies reviewed drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs without appearing in other service records. The higher share of payments did not align with the size of the beneficiary enrollment. The OIG was also concerned about findings in which almost all of one company’s HRAs were conducted in beneficiaries’ homes, a setting where it’s more likely that the HRA is conducted by a vendor hired by MA companies rather than the beneficiary’s primary care provider. The OIG said that raises concerns about the quality of care coordination for those beneficiaries and the validity of diagnoses reported on the HRAs.

The OIG recommends that CMS provide oversight of the 20 MA companies that had a disproportionate share of the risk-adjusted payments from chart reviews and HRAs, take additional action to determine the appropriateness of payments and care for one MA company that substantially drove risk-adjusted payments from chart reviews and HRAs, and perform periodic monitoring to identify MA companies that had a disproportionate share of risk-adjusted payments from chart reviews and HRAs. The OIG said it will provide information to CMS on the companies which had a substantially disproportionate share of risk-adjusted payments from diagnoses that were only reported on chart reviews and/or HRAs. CMS said it will consider these recommendations as it determines policy options for future years.

 

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

On September 24, CMS published Medicare Claims Processing Transmittal 10920 regarding the updates to diagnosis codes eligible for the ESRD PPS co-morbidity payment adjustment. The update adds two new codes (D55.21 and D55.29) and deletes one code (D55.2) to the list of codes eligible for this payment adjustment.

Effective date: October 1, 2021

Implementation date: October 4, 2021

 

Comment Request: Transcatheter Valve Therapy (TVT) Registry; Healthcare Fraud Prevention Partnership (HFPP) Data Sharing and Information Exchange

On September 24, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:

• Transcatheter Valve Therapy (TVT) Registry
• Healthcare Fraud Prevention Partnership (HFPP) Data Sharing and Information Exchange

Comments are due to the OMB desk officer by October 25, 2021.

 

Comment Request: Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act Section 1003 Demonstration Evaluation; Medicaid Drug Use Review (DUR) Program

On September 24, CMS published a Comment Request in the Federal Register regarding the following information collections:

• Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act Section 1003 Demonstration Evaluation
• Medicaid Drug Use Review (DUR) Program

Comments are due by November 23, 2021.