This week in Medicare updates–1/25/2017
Recommendations to Providers Regarding Cyber Security
On January 13, CMS posted a Memorandum reminding providers to keep current with cyber security best practices to mitigate attacks. CMS also outlined resources available to assist facilities when reviewing their security and IT programs in the Memorandum.
Delayed Implementation of End Stage Renal Disease (ESRD) Interim Final Rule with Comment (IFC) – Third Party Payment
On January 13, CMS published a Memorandum regarding the delayed implementation date of the ESRD IFC concerning third party payment requirements for dialysis facilities, which was published in the Federal Register December 14, 2016. Pursuant to a Temporary Restraining Order issued on January 12, 2017, which temporarily enjoins implementation of the rule pending further order of the court, use of the interim surveyor worksheet and enforcement of the provisions will cease until further notice.
2016 Hospital Appeals Settlement Process Reminder
On January 17, CMS posted an update on its Hospital Appeals Settlement Process 2016 website, reminding hospitals that the 2016 Hospital Appeals Settlement Process is open until January 31, 2017. Interested providers should submit an Expression of Interest by January 31, 2017.
Procedure Changes for the ALJ Level of Appeals for Medicare Claims and Entitlement, Medicare Advantage Organization Determinations, and Medicare Prescription Drug Coverage Determinations
On January 17, CMS posted a Final Rule in the Federal Register regarding the revision of the procedures that HHS follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage, and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures HHS follows at the CMS and Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level.
National Coverage Analysis (NCA) for Leadless Pacemakers (CAG-00448N)
On January 18, CMS issued a Decision Memorandum regarding Leadless Pacemakers. CMS is finalizing its proposal to cover leadless pacemakers through Coverage with Evidence Development (CED). In addition to covering the pacemakers when procedures are performed in FDA-approved studies, CMS will also cover, in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA-approved label for devices that have either an associated ongoing FDA-approved post-approval study or have completed an FDA post-approval study.
New Funding to Help Combat the Zika Virus
On January 18, CMS posted a Press Release announcing $66.1 million in funding to help combat the Zika virus. Funds will support prevention activities and treatment services for health conditions related to the Zika virus, including improving provider capacity and capability.
New Participants for Alternative Payment Models
On January 18, CMS posted a Press Release announcing that more than 359,000 clinicians are confirmed to participate in four of CMS’ Alternative Payment Models in 2017. The Medicare Shared Savings Program (Shared Savings Program), Next Generation Accountable Care Organization Model, Comprehensive End-Stage Renal Disease Care Model and Comprehensive Primary Care Plus Model all apply the concept of paying for quality and effectiveness of care given to patients in different healthcare settings, according to CMS.
Health Care Fraud and Abuse Control Program Fact Sheet
On January 18, CMS posted a Fact Sheet regarding the Health Care Fraud and Abuse Control Program. In Fiscal Year 2016, the government recovered over $3.3 billion as a result of healthcare fraud judgements, settlements and additional administrative impositions in healthcare fraud cases and proceedings. Since its inception, the program has returned more than $31 billion to the Medicare Trust Funds.
Utah Nursing Home and Owner Agree to 30 Year Exclusion
On January 18, the OIG published information regarding Deseret Health Group and Jon Robertson of Bountiful, Utah, which agreed to be excluded from participation in all federal healthcare programs for 30 years. According to the OIG website, Deseret Health Group and Robertson allegedly failed to:
- Provide adequate care planning and assessments of residents
- Provide medications, treatments, laboratory tests, physical therapy, and other services ordered by residents' physicians
- Properly use and/or administer psychotropic drugs
- Follow appropriate pressure ulcer and infection control protocols for some residents
- Follow appropriate fall protocols for some residents
- Properly administer medications to some of the residents to avoid medication errors
- Provide a safe living environment for residents
- Answer some residents' call lights promptly
Southern California Physical Therapy Practice Claimed Unallowable Medicare Part B Reimbursement for Some Outpatient Therapy Services
On January 18, the OIG published a Report regarding claims for outpatient physical therapy services provided by Athletic Physical Therapy of Southern California, which improperly claimed at least $267,000 in Medicare reimbursement for outpatient physical therapy services over a 21-month period.
Northside Medical Center Incorrectly Billed Medicare Inpatient Claims with Severe Malnutrition
On January 18, the OIG published a Report regarding Northside Medical Center, in Youngstown, Ohio, which complied with Medicare billing requirements for diagnosis codes 261 and 262 for 2 of the 100 claims reviewed. Northside Medical Center incorrectly billed inpatient claims with severe malnutrition, resulting in overpayments of approximately $1.3 million over two and a half years.
Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year (FY) 2016
On January 18, the OIG and Department of Justice (DOJ) published their FY 2016 Health Care Fraud and Abuse Control Program Annual Report. During FY 2016, the government won or negotiated over $2.5 billion in healthcare fraud judgments and settlements. The DOJ opened 975 new criminal healthcare fraud investigations and filed criminal charges in 480 cases involving 802 defendants. A total of 658 defendants were convicted of healthcare fraud-related crimes during the year. OIG investigations in FY 2016 resulted in 765 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters.
OPPS Hospital Claim Issues
On January 19, CMS posted an announcement that, due to errors in the Medicare Claims Processing System, some Outpatient Prospective Payment System (OPPS) hospital claims with dates of service on or after January 1, 2017, may be overpaid. Claims with the following HCPCS codes may be impacted: 0253T, 0335T, 24361, 25420, 25444, 25445, 27442, 27871, 28715, 28730, 37229, 43266, 45389, 62360, 64580, 69717, and 75898.
In addition, eight Comprehensive Ambulatory Payment Classification (APC) Complexity Adjustment pairs were incorrectly omitted from the claims processing system:
Primary Code: Code 2: Complexity-Adjusted APC:
28300 27698 5115
28300 28306 5115
33208 C9600 5224
36902 36908 5193
36903 36908 5194
36904 36908 5193
36905 36908 5194
49653 49650 5362
A correction for these issues will be implemented on April 3. Medicare Administrative Contractors will automatically reprocess impacted claims. Providers do not need to take any action.
NCCI Edits for Institutional and Physician Claims: National Correct Coding Initiative (NCCI) edit updates for institutional claims have regularly been implemented one quarter behind the physician claim NCCI edits due to systems issues. As a result, some physician single quarter only edits were not implemented for institutional claims. Starting April 3, CMS will apply the same physician NCCI edits to institutional claims, including the single quarter only edits.
Medicare Part D – Direct and Indirect Remuneration (DIR) Fact Sheet
On January 19, CMS posted a Fact Sheet regarding the recent growth of total DIR reported by Part D sponsors. Part D sponsors and pharmacy benefits managers are engaging to a greater extent in arrangements that feature compensation after the point-of-sale, and the value of such compensation is also generally increasing. As a result, CMS has observed a growing disparity between gross Part D drug costs, calculated based on costs of drugs at the point-of-sale, and net Part D drug costs, which account for all DIR, according to CMS.
Independence at Home Demonstration Corrected Performance Year 2 Results
On January 19, CMS posted a Fact Sheet regarding the Independence at Home Demonstration, which provides chronically ill patients with a complete range of primary care services in the home setting. In the demonstration’s second year, 10,484 beneficiaries were enrolled in the 15 participating practices, and all 15 of the practices improved performance from the first performance year in at least two of the six quality measures for the demonstration. Four practices met the performance thresholds for all six quality measures.
Medicare Outpatient Observation Notice (MOON) Instructions
On January 20, CMS posted Transmittal 3695 to update Chapter 30 of the Medicare Claims Processing Manual to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, form instructions. The MOON was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services and are not an inpatient of the hospital or critical access hospital. The form instructions provide guidance for proper issuance of the MOON.
Effective date: February 21, 2017
Implementation date: February 21, 2017
New CLIA-Waived Tests
On January 20, CMS posted Transmittal 3696 to inform contractors of new Clinical Laboratory Improvement Amendments of 1988 (CLIA)-waived tests approved by the Food and Drug Administration so that the contractors can accurately process claims. There are 22 newly added waived complexity tests.
Effective date: April 1, 2017
Implementation date: April 3, 2017
The Process of Prior Authorization
On January 20, CMS posted Transmittal 698 regarding the prior authorization process, the process through which a request for provisional affirmation of coverage is submitted for review before the item or service is furnished and submitted for processing. The transmittal directs the Medicare Administrative Contractors (MAC) to individualized operational instructions that highlight the specifications for each new prior authorization program that CMS will implement. It also provides an overview of 42 CFR 414.234 for the Durable Medical Equipment MACs.
Effective date: No later than February 21, 2017
Implementation date: No later than February 21, 2017