This week in Medicare—6/5/2024
CMS Releases Updated Health Equity Fact Sheet Outlining Goals and How Health Equity Actions Align with CMS’ Six Strategic Pillars
On May 24, CMS published an updated Fact Sheet on its recent actions aimed at advancing health equity. The fact sheet details how these actions align with CMS’ six strategic pillars (Advance Equity, Expand Access, Engage Partners, Drive Innovation, Protect Programs, and Foster Excellence).
Swing Bed Services
On May 27, CMS updated an MLN Fact Sheet regarding swing bed service requirements for hospitals or critical access hospitals (CAH). CMS added swing bed coverage information for CAHs and clarified that they may bill for the following:
- Bed and board, nursing, and other related services
- Use of CAH facilities
- Medical social services
- Drugs and biologicals
- Supplies, appliances, and equipment for inpatient hospital care and treatment and diagnostic or therapeutic items or services they, or others, provide under arrangement
State Operations Manual (SOM) Appendix M-Hospice and Appendix G-Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Revisions to Include Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs)
On May 28, CMS published a Memorandum to state survey agency directors regarding hospice, RHC, and FQHC staffing and personnel requirements for MFTs and MHCs. CMS is revising guidance in Appendices M and G of the State Operations Manual to reflect changes in the 2024 Medicare Physician Fee Schedule final rule.
The hospice interdisciplinary team must now include at least one social worker, MFT, or MHC, and the hospice personnel requirements were also updated to add these disciplines. The RHC and FQHC staffing and personnel requirements were modified to include MFTs and MHCs as part of the collaborative team approach to providing services.
Effective date: Immediately. Please communicate to all appropriate staff immediately.
Medicare Remains Vulnerable to Fraud, Waste, and Abuse Related to Off-the-Shelf Orthotic Braces, Which May Result in Improper Payments and Impact the Health of Enrollees
On May 29, the OIG published a Portfolio on Medicare vulnerabilities related to off-the-self (OTS) orthotic braces. After reviewing its previous work related to OTS braces, the OIG identified the following vulnerabilities:
- Medicare paid for potentially unallowable replacement OTS braces that did not meet reasonable useful lifetime requirements
- Medicare paid for OTS braces that were ordered by providers who did not have treating relationships with the enrollees
- The majority of new suppliers were located in geographic areas known to have high levels of Medicare fraud and furnished OTS braces ordered by providers who did not have treating relationships with enrollees
- CMS has not fully used its authority to adjust Medicare allowable amounts for OTS braces to be reasonably comparable with payments made by select non-Medicare payers
- Medicare paid for OTS braces that were marketed to enrollees by telemarketers using prohibited direct solicitation
- Payments to suppliers for fraudulently billed OTS braces have cost Medicare millions of dollars
The OIG also analyzed Medicare claims data from CY 2018 – 2020 and found that these vulnerabilities are still present. Of note, the OIG determined that Medicare paid suppliers $66.4 million for potentially unallowable replacement OTS braces during this audit period. Medicare also paid more than $1 billion for OTS braces ordered by physicians who did not have treating relationships with the enrollees. In addition, Medicare paid new suppliers $431 million for OTS braces, and 75% of the sampled new suppliers were located in geographic areas known to have high levels of Medicare fraud.
The OIG said that these issues could result in improper payments, potential harm to enrollees, and Medicare paying more for OTS braces than other payers. The OIG provided recommendations to CMS to address each vulnerability identified in the report, but the agency did not explicitly concur or disagree with the recommendations.
CMS Releases Fifth Annual Report on Evaluation of Bundled Payments for Care Improvement Advanced Model
On May 29, CMS published the fifth annual Evaluation Report on the Bundled Payments for Care Improvement (BPCI) Advanced Model. The model tests whether holding participants financially accountable for care costs and quality can reduce Medicare spending, as well as maintain or improve care quality. The report provides insights on BCPI Advanced participants in 2021, the fourth year of the model’s implementation.
The BCPI Advanced Model reduced total episode payments relative to the comparison group by $930 per episode, or 3.5% of the baseline mean, in 2021. The model resulted in approximately $465 million in net savings to Medicare in 2021, and this amount offsets the nearly $180 million in combined losses from the model’s first three years of implementation.
Medical Review Policies for Signature Requirements
On May 30, CMS published Medicare Program Integrity Transmittal 13556, which rescinds and replaces Transmittal 12663, dated May 9, to clarify that the effective date is for reviews completed on or after June 10.
The original transmittal was issued to clarify signature requirements for both prior authorization and regular medical review processes.
Effective date: June 10, 2024 - The effective date is for reviews completed on or after June 10, 2024
Implementation date: June 10, 2024
CMS Releases the Final Evaluation Report for the Oncology Care Model
On May 30, CMS published the final Evaluation Report for the Oncology Care Model (OCM). OCM is an alternative payment model based on six-month episodes for cancer care for fee-for-service Medicare beneficiaries undergoing chemotherapy treatments. The six-year model began in July 2016 and ran for 11 consecutive six-month performance periods until June 2022. The report covers findings from all performance periods.
OCM resulted in lower healthcare expenditures during the six-month episode of care, driven by higher-value use of supportive care drugs to prevent neutropenia and caner-related bone fractures. Although the model reduced episode payments by 2.1%, it ultimately resulted in over $600 million in net losses.
Combined Common Edits/Enhancements Modules (CCEM) Code Set Update
On May 31, CMS published Medicare Claims Processing Transmittal 12660 regarding the regular updates to the CCEM code set.
Effective date: October 1, 2024
Implementation date: October 7, 2024
CMS Releases Diabetes Impact Report Summarizing Advances Made in Improving Diabetes Care
On May 30, CMS released a Report to highlight actions taken by the agency in 2023 to improve diabetes care. The report details advancements in prevention, screening, and diagnosis, as well as access to treatment, services, and support.
CMS Announces the Release of 2022 Quality Payment Program Performance
On May 30, CMS published a Fact Sheet to announce that the 2022 Quality Payment Program (QPP) performance information has been released for doctors, clinicians, groups, virtual groups and Accountable Care Organizations on the Medicare.gov compare tool and in the Provider Data Catalog.
Changing the Frequency of No-Pay Medicare Summary Notice (MSN) Mailings from Every 90 Days to Every 120 Days
On May 31, CMS published Medicare Claims Processing Transmittal 12664 to change the frequency of MSN mailings from every 90 days to every 120 days.
Effective date: October 1, 2024
Implementation date: October 7, 2024
July 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On May 31, CMS published Medicare Claims Processing Transmittal 12665 regarding the July 2024 update to the OPPS. Changes include product and administration codes for PEMGARDA, 26 new PLA codes, 34 new CPT Category III codes, and more.
CMS published MLN Matters 13632 on the same date to accompany the transmittal.
Effective date: July 1, 2024
Implementation date: July 1, 2024
July 2024 Integrated Outpatient Code Editor (I/OCE) Specifications Version 25.2
On May 31, CMS published Medicare Claims Processing Transmittal 12666 regarding the July 2024 update to the I/OCE. The transmittal includes an attachment describing all of the changes for the July update.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Clarification of Liability for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Claims Overlapping Inpatient Hospital Stays
On May 31, CMS published One-Time Notification Transmittal 12667 to update the denial liability from a patient responsibility liability to a contractual obligation liability.
Effective date: July 1, 2024
Implementation date: July 1, 2024