This week in Medicare updates – 11/22/2017
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing
On November 8, CMS released Medicare Claims Processing Transmittal 3877 regarding the 2018 annual update to the list of HCPCS codes used by Medicare systems to enforce consolidated billing of home health services. The transmittal was originally issued October 6, 2017, but was not posted online until November, as it was considered sensitive material.
On November 13, CMS published MLN Matters 10308 to accompany the transmittal.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Comment Request: Hospital Conditions of Participation and Supporting Regulations; Fee-for-Service Recovery Audit Prepayment Review Demonstration and Prior Authorization Demonstration
On November 13, CMS published a Comment Request in the Federal Register regarding its intent to collect information from the public on the following collections:
- Hospital Conditions of Participation and Supporting Regulations
- Fee-for-Service Recovery Audit Prepayment Review
Comments on the above collections are due by January 12, 2018.
Updated Corporate Integrity Agreements (CIA) Reportable Event Settlements
On November 15, the Office of the Inspector General updated its list of CIA Reportable Events with three new settlements reached with three different skilled nursing facilities on November 6 following allegations that each facility employed or contracted an individual it knew or should have known was excluded participation in federal healthcare programs. These settlements include:
- C.P.C.H., Inc., d/b/a Chatsworth Park Health Care Center (CPHCC), reached a $32,114.64 settlement agreement with OIG.
- Northwest Care-Shoreline, Inc., d/b/a Park Ridge Care Center (PRCC), reached a $45,353.72 settlement agreement with OIG.
- P.T.C.H., Inc., d/b/a Palm Terrace Care Center (PTCC), reached a $765,637.68 settlement agreement with OIG.
Update to OIG Work Plan
On November 15, the Office of the Inspector General updated its Work Plan to include a review of Medicare Claims on Which Hospitals Billed for Severe Malnutrition. The OIG says it will review the accuracy of Medicare payments for the treatment of severe malnutrition to determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes on inpatient hospital claims for treating severe types of malnutrition.
Top Management and Performance Challenges Facing HHS
On November 15, the Office of the Inspector General published a List of the 10 top management and performance challenges facing the Department of Health and Human Services in 2017. The list includes:
- Curbing the opioid epidemic
- Improving care for vulnerable populations
- Ensuring integrity in managed care and other programs delivered through private insurers
- Improving financial and administrative management and reducing improper payments
- Protecting HHS data, systems, and beneficiaries from cybersecurity threats
Qualified Medicare Beneficiary Status Indicator
On November 15, CMS issued Medicare Claims Processing Transmittal 3920, which rescinds and replaces Transmittal 3802, dated June 28, 2017, to revise the Medicare Summary Notice message number in one of the business requirements and to extend that requirement to the April 2018 release. The original purpose of the change request was to create an indicator of Qualified Medicare Beneficiary status in the claims processing systems to reflect that the beneficiary lacks Medicare cost-sharing liability.
CMS issued a revised MLN Matters 9911 on November 16, 2017, to accompany the revisions to the transmittal.
Effective date: October 2, 2017 - for claims processed on or after this date
Implementation date: July 3, 2017 - CWF: Implementation of BRs 9911.1, 9911.1.1, 9911.1.2, and 9911.1.3; Design only and draft trailer layout provided to SSMs for BR 9911.2.1; VMS, MCS: analysis, design, and coding; FISS: analysis and design; October 2, 2017 - CWF: Implementation of remaining Brs; FISS, VMS, MCS: coding, testing, and implementation; April 2, 2018 - FISS implementation of BR 9911.14
Proposed Rule: Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program
On November 16, CMS published a Proposed Rule in the Federal Register to propose updates to the Medicare Advantage and prescription drug benefit program. If finalized, the rule will help increase access for Part D Medicare enrollees to more affordable prescription drugs. The rule also includes a proposal to implement requirements from the Comprehensive Addiction and Recovery Act of 2016 which would designate opioids as frequently abused drugs and allow for Part D sponsors to voluntarily implement a drug management program that limits at-risk beneficiaries’ access to frequently abused drugs.
CMS released a Fact Sheet and a Press Release on the rule. Comments on the rule must be received no later than 5 p.m. on January 16, 2018.
Advisory Opinion on Credit to Policyholders Using Network Hospital for Inpatient Stay
On November 16, the Office of the Inspector General published Advisory Opinion 17-06 regarding the use of a “preferred hospital” network as part of Medicare Supplemental Health Insurance policies. The opinion addresses whether an agreement in which an insurance company would indirectly contract with hospitals for discounts on otherwise applicable Medicare inpatient deductibles for its policyholders and offer a premium credit of $100 to policyholders who use a network hospital for an inpatient stay would constitute grounds for the imposition of sanctions under two civil monetary penalty provisions.
The OIG concluded that in this specific case, it would not impose sanctions for the following reasons:
- Neither the discounts nor the premium credit would increase or affect per-service Medicare payments
- The arrangement would be unlikely to increase utilization, affect competition among hospitals, or affect professional medical judgment
- The arrangement would operate transparently in informing policyholders of their freedom to choose any hospital without incurring additional liability or a penalty
- The premium credit would essentially serve the same purpose and effect as a differential in coinsurance or deductible amount
Medicare Compliance Review of Rush University Medical Center
On November 16, the Office of the Inspector General published a Report on the results of a review of Rush University Medical Center’s compliance in billing inpatient and outpatient services. The OIG found that the hospital did not comply with Medicare billing requirements for 57 of the 120 claims reviewed by the OIG, resulting in a total of $10.2 million in overpayments during the review period of 2014 - 2015.
Most of the billing errors were found on inpatient claims, as the OIG found 46 inpatient claims did not meet documentation requirements for the higher acute inpatient rehabilitation level of care. An additional five inpatient claims billed Medicare with an incorrect DRG code.
The OIG recommends the hospital refund the Medicare contractor for the $10.2 million in overpayments, exercise reasonable diligence to identify and return any similar overpayments received outside of the review period, and strengthen controls to ensure full compliance with Medicare requirements. The hospital generally disagreed with the OIG’s findings and recommendations.
2018 Annual Update to the Therapy Code List
On November 16, CMS issued Medicare Claims Processing Transmittal 3924, which rescinds and replaces Transmittal 3887, dated October 20, 2017, to include all coding revisions made to the HCPCS and CPT codes used by therapists to report orthotic and prosthetic management and training services. CMS also noted that the transmittal is no longer sensitive/controversial and may now be posted to the Internet.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2018 - Recurring File Update
On November 16, CMS issued Medicare Claims Processing Transmittal 3922, which rescinds and replaces Transmittal 3882, dated October 13, 2017, to include provider education. The original change request, which updates the FQHC PPS base payment rate and Geographic Adjustment Factors (GAFs) for the FQHC Pricer, is also no longer sensitive/controversial and may now be posted to the Internet.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
On November 17, CMS issued Medicare Claims Processing Transmittal 3923 to provide the April 2018 quarterly update to the list of HCPCS codes subject to the consolidated billing provision of the Home Health Prospective Payment System.
Effective date: April 1, 2018
Implementation date: April 2, 2018
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update
On November 17, CMS issued Medicare Benefit Policy Transmittal 238 regarding the addition of payment clarification and other policy information to Chapter 13 (RHC and RQHC Services) of the Medicare Benefit Policy Manual.
Effective date: February 15, 2018
Implementation date: February 15, 2018
Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)
On November 17, CMS issued Medicare Claims Processing Transmittal 3921 to inform Medicare Administrative Contractors (MAC) that Section C, Topical Application of Oxygen will be removed from NCD 20.29. Effective April 3, 2017, MACs will be responsible for determining coverage of topical oxygen for the treatment of chronic wounds.
Effective date: April 3, 2017
Implementation date: December 18, 2017
Implementation of Changes to Certificate of Medical Necessity (CMN) and CMN DME Information Form (CMN DIF) as a Result of the New Medicare Card Project
On November 17, CMS issued One-Time Notification Transmittal 1978 to instruct DME Medicare systems contractors to update their systems to implement CMN and CMN DIF changes for the new Medicare Beneficiary Identifier (MBI), including removing the Health Insurance Claim Number (HICN) with the new MBI and adding an expiration date to each form.
Effective date: April 1, 2018 - effective date based on process date
Implementation date: April 2, 2018
Updates to Provider Reimbursement Manual Chapter 40, Hospital and Hospital Health Care Complex Cost Report
On November 17, CMS issued Transmittal 12 and an accompanying form regarding changes to the Provider Reimbursement Manual. The transmittal clarifies and corrects existing instructions, incorporates additional statutory and regulatory changes, and adds a checkbox to allow a provider to elect and sign the Certification and Settlement Summary page of the Medicare cost report using an electronic signature.
Effective date: Cost Reporting Periods ending on or after August 31, 2017