This week in Medicare updates—12/21/2022
CMS Names Members of New Ground Ambulance and Patient Billing (GAPB) Advisory Committee
On December 13, CMS published a News Alert to announce that it has named to the new GAPB Advisory Committee, which is expected to provide recommendations to inform policy changes that will improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for those services, prevent balance billing to consumers, and evaluate the feasibility of implementing proposals for legislation and enforcement at the state and federal levels. The committee will meet at least twice during 2023 and is expected to release a final report within 180 days of its initial meeting.
On December 16, CMS published a Notice in the Federal Register to announce that the first meeting of the GAPB Advisory Committee will be held on January 17 and 18, 2023.
Corrections: FY 2023 IPPS Final Rule and Previous Correction Notice
On December 13, CMS published a Correction Notice in the Federal Register regarding corrections for typos and technical errors in the FY 2023 IPPS Final Rule as well as the previous correction notice that was published in the Federal Register on November 4. Some of these corrections include updates to computational errors from the direct graduate medical education (DGME) Medicare Advantage payment table on page 49075 of the August final rule and a correction to the outlier fixed-loss cost threshold for FY 2023 that was inadvertently omitted from the November correction notice.
Effective date: This correction is effective on December 12, 2022.
Applicability date: This correction is applicable for discharges beginning October 1, 2022.
National Health Spending Grew Slightly in 2021
On December 14, CMS published a Press Release regarding the 2021 National Health Expenditures (NHE) Report, which found that US health care spending increased in 2021 by 2.7% to reach a total of $4.3 trillion in total national health care spending. This was a far slower increase than the 10.3% jump in 2020, and CMS attributed the slower growth to the decline in government expenditures for health care that followed strong growth in 2020 due to the COVID-19 pandemic response. The share of the GDP devoted to health decreased from 19.7% in 2020 to 18.3% in 2021, but that is still higher than the 17.6% share from 2019. Medicare spending increased by 8.4% in 2021, a significant jump from a 3.5% increase in 2020.
Proposed Rule: CY 2023 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Programs
On December 14, CMS published a draft copy of a Proposed Rule regarding the policy and technical changes for CY 2024 Medicare Advantage (MA) plans, Part D plans, and Programs of All-Inclusive Care for the Elderly (PACE). Policies in the rule were informed by feedback from a July 2022 request for information from which CMS received approximately 4,000 responses. Proposals include multiple changes for prior authorization for MA organizations, such as:
- A requirement that MA organizations include a physician or other health care professional who has expertise in the field of medicine appropriate for the service in question to be involved before an MA plan can deny coverage
- A requirement for MA plans to establish a Utilization Management Committee to review policies annually and ensure consistency with FFS Medicare’s national and local coverage decisions and guidelines
- Establish continuity of care provisions such that a prior authorization approval for an enrollee will remain valid for the full course of treatment
The rule also includes proposals regarding improved access to behavioral health care, restrictions on misleading marketing tactics, new requirements for Part D sponsors related to medication therapy management, and more.
CMS published a Press Release and Fact Sheet on the rule on the same date. Comments are due by February 13, 2023. The rule is scheduled to be published in the Federal Register on December 27.
Updated OIG Work Plan
On December 15, the OIG updated its Work Plan with the following new items:
- Implementation of Inflation-Indexed Rebates for Part B Drugs
- Audit of Medicare Part B Opioid Use Disorder Treatment Services Provided by Opioid Treatment Programs-Bundled Payments and Telehealth Services
2022 Top Unimplemented Recommendations
On December 15, the OIG published a List of its top 25 unimplemented recommendations which it believes would help reduce fraud, waste, and abuse across HHS programs. The list includes CMS addressing topics such as inappropriate nursing home discharges, system edit processes for DME to prevent improper payments for services provided to hospice beneficiaries, monitoring and oversight of Medicare Advantage organizations, and more.
April 2023 Update to the MS-DRG and Medicare Code Editor (MCE) Version 40.1 for ICD-10 Diagnosis Codes for Collection of Health-Related Social Needs (HRSN) and New ICD-10-PCS Codes
On December 15, CMS published Medicare Claims Processing Transmittal 11746 regarding the implementation of 42 new ICD-10-CM codes for HRSN collection. The transmittal also implements 34 new ICD-10-PCS codes into the MCE and MS-DRG Grouper.
Effective date: April 1, 2023
Implementation date: April 3, 2023
Intravenous Immune Globulin (IVIG) Demonstration: Payment Update for 2023
On December 15, CMS published Demonstrations Transmittal 11750 regarding the 2023 payment rate for the IVIG Demonstration. The CY 2023 rate is $392.56.
Effective date: January 1, 2023 - this is the date the updated payment will be effective.
Implementation date: January 3, 2023
Updating CY 2023 Medicare Diabetes Prevention Program (MDPP) Payment Rates
On December 15, CMS published One-Time Notification Transmittal 11751 regarding the MDPP payment rates for CY 2023. CMS included a separate document containing the codes, long descriptors, payment descriptions, and CY 2023 payment rates listed out for each MDPP service.
Effective date: January 1, 2023
Implementation date: January 3, 2023
April 2023 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On December 15, CMS published Medicare Claims Processing Transmittal 11752 regarding the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. This update applies to the quarterly files from April 2022, July 2022, October 2022, January 2023, and April 2023.
Effective date: April 1, 2023
Implementation date: April 3, 2023
New Medicare Part B Immunosuppressant Drug Benefit (PBID) - Implementation
On December 16, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 11646, which rescinds and replaces Transmittal 11520, dated July 28, to remove business requirement 12804-04.7 and to add business requirements 12804-04.15 and 12804-04.16. The transmittal is no longer sensitive and is now being posted to the internet. The transmittal states it was posted November 2, but it was not posted until December 16. The transmittal was published to implement the new PBID benefit, which allows individuals whose Medicare entitlement based on ESRD ends following a kidney transplant to continue enrollment under Part B for the coverage of immunosuppressive drugs.
CMS published MLN Matters 12804 on December 16 to accompany the transmittal.
Effective date: January 1, 2023
Implementation date: January 3, 2023
National Correct Coding Initiative (NCCI): Annual Policy Manual Update
On December 16, CMS published the updated version of the NCCI Manual. CMS also redesigned the NCCI webpage and now includes an FAQ on billing and coding advice regarding the NCCI program.
This version of the NCCI manual is effective January 1, 2023.