This week in Medicare updates—11/30/2022
The Importance of Timely Use of COVID-19 Therapeutics
On November 22, CMS published a Memorandum to state survey agency directors regarding timely access to COVID-19 therapeutics and vaccines, especially in congregate care settings. The memo directs providers in general–but nursing homes in particular–to review and reinforce infection control protocols and review the latest information on clinically appropriate therapeutics. The memo also includes a reminder that nursing homes are required to educate residents and staff on the risks and benefits of COVID-19 vaccines, offer to administer the vaccine, and report resident and staff vaccination data to the CDC’s National Healthcare Safety Network.
CMS published a Press Release to accompany the memo on the same date.
Effective date: Immediately. This memo does not reflect new survey guidance nor policy and is considered to be a reference memo only.
Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for CY 2023
On November 23, CMS published Medicare Claims Processing Transmittal 11718 regarding an update to the per-visit payment limit for RHCs in CY 2023. The payment varies by type (provider-based, grandfathered, etc.) of RHC. The transmittal also includes information on the timing of cost reports used to establish the payment limit for specified provider-based RHCs.
CMS published MLN Matters 12999 on the same date to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023
New Waived Tests
On November 23, CMS published Medicare Claims Processing Transmittal 11717 regarding new CLIA-waived tests. There are eight newly added waived complexity tests in this update.
CMS published MLN Matters 12996 on the same date to accompany the transmittal.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Updates to Independent Renal Dialysis Facility Cost Report, Form CMS-265-11
On November 23, CMS published Provider Reimbursement Manual Transmittal 7 regarding updates to the independent renal dialysis facility cost report (Form CMS-265-11). Changes were made generally and to various worksheets. Some of the changes include updated burden hours and expiration dates, additional lines to report full-time equivalent employees, additional ways to report pediatric supplies, and more.
Effective date: ESRD changes effective for cost reporting periods beginning on or after January 1, 2023.
Update the Common Working File (CWF) to Apply Error Code 7282 to All Applicable Detail Lines of a Claim
On November 23, CMS published One-Time Notification Transmittal 11719 regarding an update to the CWF to apply error code 7282 (Part B claims when a clinical diagnostic test or interpretation is received and is a duplicate of a previously paid record in history for the same clinical diagnostic test or interpretation) to all applicable detail lines of a claim in one cycle.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Medicare Providers Did Not Always Comply With Federal Requirements When Billing for Advance Care Planning
On November 23, the OIG published a Review regarding whether Medicare providers who received payments for advance care planning (ACP) services in an office setting complied with federal requirements. The OIG found that 466 of the 691 ACP services did not comply with federal requirements. Issues included providers claiming that they did not know that the time for ACP services had to be distinguished between time spent discussing ACP and time spent on concurrent services. Some providers said they were unaware there was a time requirement. The OIG said that, on the basis of this sample, it estimates that Medicare providers received approximately $42.3 million in payments for ACP services that did not comply with federal requirements. The OIG also noted that it found some claims where 15 or more ACP services were received during the 12-month audit period, and while that did not reflect noncompliance, it did not align with CMS guidance in an FAQ suggesting that ACP services billed multiple times for a beneficiary should include a documented change in the beneficiary’s health status, end-of-life care wishes, or both.
The OIG recommends CMS educate providers on documentation and time requirements for ACP services, instruct the MACs to recoup the money paid in error for claims in the sample, and instruct the MACs to notify providers so they can identify, report, and return similar overpayments. The OIG also recommends CMS establish requirements that address when it is appropriate to provide multiple ACP services for a single beneficiary and how these services should be documented to support the need for multiple ACP services. CMS concurred with all but the fourth recommendation.
National Government Services (NGS) Accurately Calculated Hospice Cap Amounts but Did Not Collect All Cap Overpayments
On November 25, the OIG published a Review of whether NGS accurately calculated cap amounts and collected cap overpayments in accordance with CMS requirements. The OIG found that NGS accurately calculated cap amounts and collected the vast majority of the total cap overpayments, but it did not attempt to collect $2.1 million of the $213.4 million in total cap overpayments because of its internal policy of not pursuing lookback cap calculation amounts that were less than a certain threshold. The OIG also found that NGS issued instructions to hospices against CMS requirements in which NGS told hospices to wait to submit overpayments calculated on cap determination notices until the hospice received a demand letter from NGS. This process took an average of more than two months after the due date for hospices to file the cap determination notices, thus preventing the federal government from having those funds for its use for an additional average of more than two months.
The OIG recommends NGS collect the $2.1 million in lookback overpayments and return $22,576 in lookback refunds resulting from 2019 hospice cap calculations for lookback years, discontinue its internal policy of waiving certain overpayment collections related to lookback years, and change its instructions on the cap determination notices to follow the CMS requirement that hospices remit overpayments at the time they submit their cap determination notice. NGS concurred with the third recommendation but not the first two.
Medicare Improperly Paid Physicians for Co-Surgery and Assistant-at-Surgery Services That Were Billed Without the Appropriate Payment Modifiers
On November 25, the OIG published a Review of whether Part B payments to physicians for potential co-surgery procedures complied with federal requirements. The OIG found that 69 of the 100 statistically sampled services did not comply with requirements. This included 49 services incorrectly billed without the co-surgery modifier, 14 incorrectly billed without an assistant-at-surgery modifier, and six that were incorrectly billed as duplicate services. The OIG also reviewed 127 corresponding services and found that 62 of those did not comply with federal requirements, as 33 were incorrectly billed without the co-surgery modifier, 16 were incorrectly billed without an assistant-at-surgery modifier, and 13 were incorrectly billed as duplicate services. The OIG determined that these errors resulted in $56,016 in overpayments.
The OIG recommends CMS recover the portion of the $56,016 in Part B overpayments within the claim reopening period, instruct Medicare providers to identify, return, and report any similar overpayments, strengthen its system control to detect and prevent improper payments for these types of services, and update Medicare requirements and corresponding educational material to improve providers’ understanding of the Part B billing requirements for co-surgery procedures. CMS concurred with these recommendations.
Comment Request: Medicare Part C and Medicare Part D Enrollment Form Interviews; more
On November 25, CMS published a Comment Request in the Federal Register regarding the submission of the following information collections for OMB review:
- Medicare Part C and Medicare Part D Enrollment Form Interviews
- Advance Beneficiary Notice of Noncoverage (ABN)
- Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
- Social Security Office (SSO) Report of State Buy-In Problem
Comments are due to the OMB desk officer by December 27.