This week in Medicare updates—7/20/2022
Report to Congress: Unified Payment for Medicare-Covered Post-Acute Care
On July 7, CMS published a Report to Congress regarding a potential unified prospective payment system for post-acute care (PAC). This type of payment system was included as a provision of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. In this report, CMS presented a prototype for what the unified PAC PPS could be and the data analysis used to design and calibrate it. Because this type of PPS is in the very early stages of development, the report does not include any legislative recommendations, as CMS will be performing additional analysis on this topic. However, the report provides an early framework of what could be coming in terms of PAC payments in future years.
Reinforcement of EMTALA Obligations Specific to Patients Who are Pregnant or are Experience Pregnancy Loss (QSO-21-22-Hospitals-Updated July 2022)
On July 11, CMS published a Memorandum to state survey agency directors regarding requirements under EMTALA to provide necessary treatment to pregnant patients, including abortion services. This memorandum was issued following the Supreme Court’s decision to overturn Roe v. Wade via Dobbs v. Jackson Women’s Health Organization. The memo emphasizes that EMTALA, as a federal law, protects providers who offer legally-mandated, life- or health-saving abortion services in emergency situations despite restrictions imposed by state laws. It details specific provisions of EMTALA which apply to these types of cases, notes that a hospital cannot cite state law as the basis for a transfer in an emergency, describes hospital obligations, and details enforcement of these provisions.
CMS published a Press Release regarding this issue on the same date.
Effective date: Immediately. This policy should be communicated to all survey and certification staff and managers immediately.
CLIA Proficiency Testing Regulations Related to Analytes and Acceptable Performance Final Rule
On July 11, CMS published a Final Rule in the Federal Register regarding updates to proficiency testing (PT) regulations under CLIA to address current analytes and newer technologies in a way that reduces burden and reflects more modern technology than when these regulations were established in 1992. The rule also makes technical changes to PT referral regulations to better align them with the CLIA statute.
CMS published a Memorandum on the same date regarding the specifics of the modifications to these regulations.
Dates: Effective August 10, 2022, except for amendments to §§4493.2 and 493.801-493.959 (amendatory instructions 2 and 5 through 21), which are effective July 11, 2024.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Qtr FY 2022
On July 14, CMS published Medicare Financial Management Transmittal 11495 regarding the updated interest rate for Medicare overpayments and underpayments. The latest private consumer rate has been changed to 8.75%.
Effective date: July 18, 2022
Implementation date: July 18, 2022
Claim Status Category and Claim Status Codes Update
On July 14, CMS published Medicare Claims Processing Transmittal 11493 regarding the updates to the Claim Status and Claim Status Category Codes used for the ASC X12 276/277 Health Care Claim Status Request and Response and the ASC X12 277 Health Care Claim Acknowledgment transactions.
Effective date: October 1, 2022
Implementation date: October 3, 2022
CY 2023 Outpatient Prospective Payment System (OPPS) Proposed Rule
On July 15, CMS published a draft copy of the CY 2023 OPPS Proposed Rule, which is scheduled to be published in the Federal Register on July 26. While the rule proposes paying for drugs and biologicals acquired through the 340B program at average sales price (ASP) minus 22.5%, it notes that the Supreme Court’s decision in American Hospital Association v. Becerra now prevents CMS from varying payment rates for drugs and biological in the way the 340B payment currently varies. CMS did not have sufficient time before publishing the proposed rule to account for the Supreme Court’s decision, and it noted in the fact sheet for the rule that it anticipates applying a rate of ASP plus 6% for 340B drugs in the final rule. The rule proposes updates to both OPPS and ASC PPS payment rates by 2.7% for 2023. Other proposals in the rule include:
- Establishing provider enrollment procedures and payment rates for rural emergency hospitals (REH)
- Removing 10 services from the inpatient-only list and adding one service to the ambulatory surgical center (ASC) covered procedures list
- Continuing coverage for behavioral health services furnished remotely by hospital staff to beneficiaries in their homes beyond the end of the public health emergency (PHE) as long as the beneficiary receives an in-person service once every 12 months
- Adding facet joint injections and nerve destruction as an additional service that would require prior authorization
CMS is seeking comments on a variety of topics within the rule, including whether there is additional data CMS could release on mergers/acquisitions/consolidations/changes in ownership in addition to the hospital and skilled nursing facility data CMS current releases. It also seeks comments on methodologies for counting organs to calculate Medicare’s share of organ acquisition costs and comments on payment approaches to use for software services. Comments are due on September 13.
CMS published a Fact Sheet on the rule, Fact Sheet on the REH provisions, and Press Release to accompany the rule.