This week in Medicare updates—3/29/2023
Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Geisinger Health Plan Submitted to CMS
On March 20, the OIG published a Review of whether select diagnosis codes that Geisinger Health Plan submitted to CMS for use in the risk adjustment program complied with federal requirements. The OIG conducted the audit by sampling 270 unique enrollee-years across nine groups of high-risk diagnosis codes for which Geisinger received higher payments for 2016 and 2017. The OIG found that diagnosis codes for 224 of the 270 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records or Geisinger could not find the medical records to support the diagnosis codes. The OIG found that based on the results of the sample, Geisinger received at least $566,476 in net overpayments in 2016 and 2017.
The OIG recommended that Geisinger refund the federal government for the $566,476 in overpayments, identify and return similar overpayments, and examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements. Geisinger disagreed with all of the findings and recommendations in the report, but the OIG stood by its findings.
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
On March 21, CMS published Medicare Claims Processing Transmittal 11917, which rescinds and replaces Transmittal 11834, dated February 16, to add business requirement 13014.9.1 for VMS. The original transmittal was published regarding implementation of the system changes necessary to accommodate the changes to insulin pricing and provider/supplier payments.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Guidance and Survey Process for Reviewing Home Dialysis Services in a Nursing Home
On March 22, CMS published a Memorandum to state survey agency directors which revises previous guidance issued for care at home provisions for nursing home residents receiving home dialysis. CMS has received questions, comments, and feedback on this topic since that time, and it is therefore now providing clarification on dialysis services for these beneficiaries via this revised memorandum.
Effective date: Immediately. This memo should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators.
Indian Health Services (IHS) Hospital Payment Rates for CY 2023
On March 23, CMS published Medicare Claims Processing Transmittal 11919 regarding the annual update of IHS payment rates for CY 2023. Novitas Solutions, which processes IHS hospital claims, will be making payment adjustments as necessary resulting from the rate changes for the 2023 calendar year.
Effective date: January 1, 2023
Implementation date: June 26, 2023
July 2023 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On March 23, CMS published Medicare Claims Processing Transmittal 11920 regarding the regular quarterly updates to the ASP and Not Otherwise Classified (NOC) drug pricing files for Part B drugs. The file will be available for download on or after June 14.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Medicare Improperly Paid Physicians for Spinal Facet-Joint Interventions
On March 24, the OIG published a Review of whether Medicare paid physicians for spinal facet-joint interventions in accordance with Medicare requirements. The OIG had previously found that Medicare improperly paid for these services, and it noted that facet-joint interventions are at risk for overutilization. This audit was conducted as a follow-up to previous audits, and it examined interventions from August 1 - October 31, 2021. The OIG found that Medicare did not pay physicians for selected facet-joint intervention sessions in accordance with Medicare requirements, as 66 of the 120 sampled sessions did not comply with at least one–if not more–of the requirements. Of the 120 sampled sessions, the OIG also found that 43 had claim lines that were billed for at least one therapeutic facet-joint injection, and 33 of those sessions should have been billed for diagnostic instead of therapeutic injections. This did not result in improper payments because the payments for therapeutic injections are the same as the payment for diagnostic injections. However, the 66 sampled facet-joint intervention sessions deemed to be paid in error totaled $18,084 in improper payments.
The OIG recommends CMS direct the MACs to recover the $18,084 in improper payments. The OIG also recommends CMS develop collaborative training programs to be used for all MAC jurisdictions and develop solutions to prevent the incorrect billing of diagnostic facet-joint injections as therapeutic facet-joint injections. CMS concurred with the OIG’s recommendations.
April 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On March 24, CMS published Medicare Claims Processing Transmittal 11927, which rescinds and replaces Transmittal 11903, to remove the HCPCS C1831-CPT 22612 code pair from Attachment A, table 1, and correct the related language associated with this code pair in the policy section B.1.b.
CMS revised MLN Matters 13143 on the same date.
Effective date: April 1, 2023
Implementation date: April 3, 2023