This week in Medicare updates—10/17/18

NCA Tracking Sheet for Ambulatory Blood Pressure Monitoring

On October 9, CMS posted a Tracking Sheet to initiate a national coverage analysis (NCA) for ambulatory blood pressure monitoring (ABPM). The requestor is seeking coverage of ABPM to diagnose hypertension in Medicare beneficiaries. The tracking sheet initiates a 30-day public comment period for the NCA, which will close on November 8, 2018.

 

CMS Announces Participants in New Value-Based Bundled Payment Model

On October 9, CMS published a Press Release regarding participation in the Bundled Payments for Care Improvement - Advanced (BPCI Advanced) Model. There will be 1,299 participants in the program, which runs from October 1, 2018 through December 31, 2023. The model builds on the BPCI Initiative, which ended on September 30, 2018. This newer model expands on the original version, as it offers bundled payments for additional clinical episodes (including outpatient episodes), provides participants with preliminary target prices before the start of each year, and qualifies as an Advanced APM in the Quality Payment Program, which therefore exempts providers from reporting requirements associated with MIPS.  

 

CMS Response to Hurricane Michael

On October 10 and 11, CMS published two press releases on actions it is taking in Hurricane Michael recovery efforts in Florida and Georgia. These actions include temporary waivers for certain Medicare requirements, special enrollment opportunities to allow for immediate access to healthcare, and steps to ensure dialysis patients can obtain services. For more information on CMS activities related to hurricane relief, visit CMS’ emergency website.   

On October 11, CMS published Special Edition MLN Matters 18021 to provide information for providers and suppliers who have beneficiaries in Florida impacted by Hurricane Michael on the special waivers and services available to assist in hurricane relief efforts.  

 

CMS Releases 2019 Star Ratings for Medicare Advantage and Part D Prescription Drug Plans

On October 10, CMS published a Press Release regarding the annual release of Star Ratings for the Medicare Advantage and Part D prescription drug plans. In 2019, approximately 74% of Medicare Advantage enrollees with prescription drug coverage are projected to be in plans with four or more stars, an increase of 1% from 2018. Data on the ratings is available on the CMS website.  

 

Updated Corporate Integrity Agreements (CIA) Reportable Event Settlements

On October 10, the OIG updated its list of CIA Reportable Events with four new settlements reached in September with entities under corporate integrity agreements who self-disclosed reportable events. In these four cases, those reportable events involved employing individuals the entity knew or should have known were excluded from participation in federal healthcare programs. These entities include:

• The Ensign Group, Avenues Healthcare, Inc., d/b/a City Creek Post-Acute, and Wellington Healthcare, Inc., d/b/a Wellington Place Living & Rehabilitation Center
• The Ensign Group, Livingston Care Associates d/b/a Timberwood Nursing and Rehabilitation Center, and 24th Street Healthcare Associates, LLC d/b/a Desert Terrace Healthcare Center
• The Ensign Group and wellington Healthcare, Inc. d/b/a Wellington Place Living and Rehabilitation Center
• The Ensign Group, Avenues Healthcare, Inc. d/b/a City Creek Post-Acute, and Cardiff Healthcare, Inc. d/b/a Paramount Health and Rehabilitation

 

Updated Provider Self-Disclosure Settlements

On October 10, the OIG published an updated List of Provider Self-Disclosure Settlements, including:

• On September 7, Washington Health System Orthopedics and Sports Medicine, of Pennsylvania, reached a $10,000 settlement with the OIG to resolve allegations it improperly submitted claims to Medicare for film X-Rays without using the FX modifier
• On September 13, Via Christi Manhattan Hospital, Inc., of Kansas, reached a $3,796,703.97 settlement with the OIG to resolve allegations that it submitted claims for medically unnecessary bronchoscopies that lacked medical documentation
• On September 20, the University of Nevada School of Medicine, Multispecialty Group Practice South, Inc., reached a $12,194.66 settlement with the OIG to resolve allegations it submitted claims to Medicare and Medicaid for items or services it knew or should have known were not provided as claimed and were false and fraudulent
• On September 24, Mountain West Derm - Blackhart, PLLC d/b/a Skin Cancer Dermatology Institute and MWD Management, LLC d/b/a United Derm Partners, of Nevada, reached a $105,538.50 settlement with the OIG to resolve allegations it billed phototherapy services using a CPT code that requires the use of a topical agent when such services should have been billed using a different code because it did not involve use of a topical agent
• On September 24, Southern Cancer Center, P.C., of Alabama, reached a $538,545.67 settlement with the OIG to resolve allegations it allowed the accrual of overpayments owed to Medicare and Medicaid, and it did not return these overpayments when it became aware of them
• On September 24, Rex Hospital, Inc. d/b/a UNC Rex Healthcare, of North Carolina, reached a $2,277,762 settlement with the OIG to resolve allegations it offered and paid remuneration to a physician it leased from a community hospital that were in excess of the community hospital’s lease fee and should have been paid by the community hospital
• On September 25, Froedtert Memorial Lutheran Hospital, of Wisconsin, reached a $1,972,729.90 settlement with the OIG to resolve allegations it submitted false claims for services rendered in its wound care clinic by registered nurses when the services were not provided pursuant to appropriate physician or non-physician practitioner supervision

The list also included eight entities who reached agreements due to employing individuals they knew or should have known were excluded from federal healthcare programs. These entities include:  

• St. Joseph Hospital, of Maine
• The General Hospital Corporation d/b/a Massachusetts General Hospital, of Massachusetts
• Roots Community Health Center, of California
• Beacon Medical Group, Inc., of Indiana
• Surgery Partners, Inc., of California
• Care Inn of Sequin d/b/a San Gabriel Rehabilitation and Care Center, of Texas
• Eye Care Associates, Inc., of Alabama
• Orlando Regional Medical Center, of Florida

 

Updated List of Excluded Individuals and Entities (LEIE)

On October 11, the OIG updated its LEIE with an updated LEIE database for download and lists of September 2018 exclusions, reinstatements, and profile corrections.

 

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Quarter Notification for FY 2019

On October 11, CMS published Medicare Financial Management Transmittal 307 regarding the new interest rate for overpayments/underpayments in the first quarter of FY 2019. The private consumer rate has been changed to 10.125%.

Effective date: October 17, 2018

Implementation date: October 17, 2018

 

Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates

On October 12, CMS published One-Time Notification Transmittal 2151 to provide instructions to A/B MACs and the Railroad Specialty MAC on updating the MDPP Expanded Model payment rates for CY 2019. The updated rates are included in an attachment to the transmittal.

Effective date: January 1, 2019

Implementation date: January 7, 2019

 

Order Requirements When Prescribing Practitioner is Also the Supplier and is Permitted to Furnish Specific Items of DMEPOS

On October 12, CMS published Medicare Program Integrity Transmittal 834 to clarify requirements for a written order when the prescribing practitioner is also the supplier and is permitted to furnish specific items of DMEPOS.

Effective date: November 13, 2018

Implementation date: November 13, 2018 - MAC Implementation; January 15, 2019 - Provider Education Only

 

Templates in Medical Review

On October 12, CMS published Medicare Program Integrity Transmittal 833 to clarify that CMS endorses clinical templates located on its own website, and contractors should consider information in those templates when conducting medical review.

Effective date: November 13, 2018

Implementation date: November 13, 2018

 

One-on-One Education

On October 12, CMS published Medicare Program Integrity Transmittal 835 to clarify the definition of one-on-one education.The revisions state education can be conducted based on reviews by MACs, RACs, or Supplemental Medical Review Contractors. For the purpose of the Targeted Probe and Educate program, letters shall not be considered one-on-one education.

Effective date: November 13, 2018

Implementation date: November 13, 2018

 

Revisions to Medicare State Operations Manual (SOM) Table of Contents, SOM Appendix A, SOM Appendix T, SOM Appendix W

On October 12, CMS published State Operations Provider Certification Transmittal 183 regarding revisions to SOM Appendix A for Hospitals and Appendix W for Critical Access Hospitals (CAH) to address new and revised regulations and interpretive guidelines related to swing-bed services. Appendix T will be deleted and information on swing-bed services for hospitals will be relocated to Appendix A.

Effective date: October 12, 2018

Implementation date: October 12, 2018