This week in Medicare updates—11/7/2018

Contract Year (CY) 2020 Medicare Advantage and Part D Flexibility Proposed Rule

On October 26, CMS published a Proposed Rule regarding updates to Medicare Advantage that would expand telehealth benefits, unify appeals processes across Medicare and Medicaid, and help CMS recover improper payments made to Medicare Advantage organizations. The expansion of telehealth benefits would allow MA plans to offer government-funded telehealth benefits to all beneficiaries, regardless of whether they live in rural or urban areas. It would also allow beneficiaries to access telehealth from home rather than requiring them to go to health care facilities. These changes would begin in plan year 2020.

CMS published a Press Release and a Fact Sheet on the same date to accompany the proposed rule. The rule was published in the Federal Register on November 1. Comments are due by December 31, 2018.

 

CMS Acts to Help with Typhoon Yutu Emergency Response

On October 26, CMS published a Press Release on actions it is taking in Typhoon Yutu recovery efforts. These actions include temporary waivers for certain Medicare requirements, special enrollment opportunities to allow for immediate access to healthcare, and steps to ensure dialysis patients can obtain services. For more information on CMS activities related to typhoon/hurricane relief, visit CMS’ emergency website.   

On October 31, CMS published Special Edition MLN Matters 18024 to provide information on the special waivers and services available to assist in typhoon relief efforts in the Northern Mariana Islands.  

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On October 29, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions agreements, including:

• On October 24, Jamie L. Sepulveda, MD, LLC (d/b/a Miami Urogynecology Center), Jamie L. Sepulveda, M.D., and Sujata Yavagal, M.D., of South Miami, Florida, reached a $173,768.08 settlement agreement with the OIG to resolve allegations that Miami Urogynecology Center submitted claims diagnostic services when therapeutic services were performed, claims for physical therapy services when they were provided by an unqualified individual, and claims for E/M services billed in conjunction with pelvic floor therapy procedures when no separate and identifiable E/M services were provided.

 

Professional Clinical Laboratory, Inc., Generally Did Not Comply With Medicare Requirements for Billing Phlebotomy Travel Allowances

On October 29, the OIG published a Review of whether Professional Clinical Laboratory, Inc., (ProLab) claimed travel allowances for clinical diagnostic lab tests in accordance with Medicare requirements. The OIG found that of the 100 travel allowance claim lines reviewed, 65 claim lines did not meet Medicare requirements. ProLab did not sufficiently support prorated miles with documentation when multiple patients were served on a single trip, resubmit claims for retroactive changes in the clinical lab fee schedule, or have documentation to support specimen collections. The OIG recommends ProLab refund Medicare an estimated $319,277 in overpayments for incorrectly billed claims within the reopening period and conduct reasonable diligence to identify and return overpayments outside of the reopening period and outside the audit period. ProLab did not respond to the OIG draft report or answer any follow-up questions upon the advice of its attorney.

 

Advisory Opinion No. 18-12

On October 29, the OIG published an Advisory Opinion regarding the use of a preferred hospital network as part of a Medigap policy whereby the insurance company would contract indirectly with hospitals for discounts on Medicare inpatient deductibles for policyholders and would subsequently provide a premium credit of $100 off the next renewal premium to policyholders using a network hospital for an inpatient stay. The requestor inquired as to whether this agreement would constitute grounds for sanctions under the civil monetary penalty prohibition on inducements to beneficiaries or the anti-kickback statute. Although the OIG determined the arrangement could implicate the prohibition on inducements to beneficiaries and the anti-kickback statute, it said it would not impose sanctions in this case for reasons discussed in the opinion memo.

 

Updated Stipulated Penalties and Exclusion for Material Breach

On October 31, the OIG updated its list of Stipulated Penalties and Exclusion for Material Breaches with one new action:

• On October 26, Pediatric Services of America, Inc., paid a stipulated penalty of $22,500 for its failure to have its Chief Compliance Officer make a quarterly report directly to the Board of Directors during the first quarter of 2017. Pediatric Services of America also did not ensure that the Compliance Committee met at least quarterly during 2017.

 

Final Rule: CY 2019 Home Health (HH) Prospective Payment System (PPS) Rate Update and CY 2020 Case-Mix Adjustment Methodology

On October 31, CMS published the display copy of a Final Rule with Comment regarding updates to the HH PPS which finalize 2019 Medicare payment updates, quality reporting changes, and the Patient-Driven Groupings Model (PDGM) case-mix methodology refinements. The rule also finalizes a change in the home health unit of payment from 60 days to 30 days for CY 2020 and discusses the implementation of temporary transitional payments from home infusion therapy services beginning January 1, 2019.

CMS issued a Press Release and Fact Sheet on the final rule on the same date. Comments are due by December 31, 2018.

Effective date: January 1, 2019

Implementation date: The PDGM case-mix methodology refinements and the change in the unit of payment from 60-day episodes of care to 30-day periods of care will be for home health services (30-day periods of care) beginning on or after January 1, 2020.

 

Final Rule: End-Stage Renal Disease (ESRD) and Durable Medical Equipment (DME) Final Rule

On November 1, CMS published the Display Copy of the End-Stage Renal Disease (ESRD) and Durable Medical Equipment (DME) Final Rule. The rule finalizes certain changes to bidding and pricing methodologies under the DME Competitive Bidding Program, includes discussion on comments it received regarding the gap-filling process for establishing new fees for DMEPOS items, updates certain ESRD payment rates, and expands the Transitional Drug Add-On Payment Adjustment.

CMS published a Press Release and Fact Sheet on the same date to accompany the final rule. The full version of the final rule is scheduled to be published in the Federal Register on November 14, 2018.

Effective date: These regulations are effective January 1, 2019, except the amendments to 42 CFR 413.234, which are effective January 1, 2020.

 

Final Rule: CY 2019 Medicare Physician Fee Schedule and QPP

On November 1, CMS published the Display Copy of the Medicare Physician Fee Schedule and QPP Final Rule. The rule finalizes significant changes to E/M coding and documentation, although CMS has delayed the consolidation of payment levels for certain level 2-4 E/M codes until 2021. CMS also rescinded its original proposal to include level 5 E/M codes into the payment consolidation. Some of the other major finalized policies include:

• Reducing the amount of documentation required for E/M visits in 2019 and 2020 so that providers will not have to re-enter information about the patient’s chief complaint and, for established office visits, providers will not need to re-record the defined list of required element when relevant information is already contained in the medical record and there is evidence the provider has reviewed that documentation
• Eliminating the requirement to document medical necessity of a home visit in lieu of an office visit
• Expanding telehealth services by adding two new codes for prolonged preventive services, allowing ESRD patients to use their homes as originating sites for telehealth, and finalizing payment for rural health clinics/federally qualified health centers for certain communication technology-based services and remote evaluation services
• Reducing the add-on payment from 6% to 3% for wholesale acquisition cost-based payments for Part B drugs during the first quarter of sales when average sales price is unavailable

The rule also finalizes multiple key policies for Year 3 of the QPP, including:

• Expanding the definition of a Merit-based Incentive Payment System (MIPS)-eligible clinician to include physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals
• Adding a third option for low-volume threshold exclusion criterion (providing 200 or fewer covered professional services paid under the Physician Fee Schedule).
• Reweighting performance category scores to 45% for Quality, 15% for Cost, 15% for Improvement Activities, and 25% for Promoting Interoperability
• Revising the definition of a high priority measure for the Quality category to include opioid-related measures
• Allowing clinicians or groups to opt-in to MIPS if they meet or exceed at least one but not all three of the low-volume threshold criteria

CMS published a Press Release and Fact Sheet on November 1 to accompany the final rule. CMS also published a Table on the same date to demonstrate how it plans to change payment for E/M codes in 2021.

Effective dates: These regulations are effective on January 1, 2019, except for the following: (1) Revisions to §§414.1415(b)(2) and (3), and 414.1420(b), (c)(2), and (3), which are effective January 1, 2020; and (2) Amendments to Part 425, which are effective on December 31, 2018.

 

A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019

On November 1, CMS published Special Edition MLN Matters 18016 regarding its 2019 Medicare Part D opioid overutilization initiatives. The article includes an overview of new safety alerts for pharmacists, drug management programs Part D can implement, and an FAQ for provider action.

Effective date: N/A

Implementation date: N/A

 

Final Rule: Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System

On November 2, CMS published the Display Copy of the OPPS and ASC final rule with comment period. The full text of the final rule is scheduled to be published in the Federal Register on November 21, 2018. The rule contains a number of policies geared toward site neutral payment. Major provisions include:

• Applying the Physician Fee Schedule (PFS)-equivalent payment rate to outpatient clinic visits provided at what are currently referred to as excepted off-campus provider-based departments (PBD) paid under the OPPS. This policy will be phased in over two years and would reduce payment to 70% of the OPPS rate in 2019 and 40% of the OPPS rate in 2020 and beyond.
• Expanding the average sales price (ASP) minus 22.5% payment rate for drugs acquired through the 340B drug discount program to those 340B drugs furnished in non-excepted off-campus PBDs.
• Revising the definition of “surgery” in the ASC payment system to account for certain “surgery-like” procedures that are assigned codes outside the CPT surgical range.
• Removing two ENT procedures and two anesthesia codes from the inpatient only list and adding one cardiac procedure to the inpatient only list for 2019.

CMS did not finalize a proposal that would have changed payment for services in new clinical families of services furnished at excepted off-campus PBDs to payment under the PFS instead of the OPPS, but it said it will continue to monitor the expansion of services in excepted off-campus PBDs.

CMS published a Press Release and Fact Sheet on the same date to accompany the final rule. It is also seeking comments no later than December 3, 2018, on payment classifications assigned to interim APC assignments and/or status indicators of new or replacement Level II HCPCS codes.

Effective date: January 1, 2019

 

Extension of Timeline for Publication of Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies

On November 2, CMS published a Notice in the Federal Register to announce the extension of the timeline for publication of the Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies final rule. Due to the complexity of the rule, number of comments received, and the collaboration it would require with the HHS’ Office of the National Coordinator for Health Information Technology, CMS said it is unable to meet the three-year timeline for publication of a final rule and is extending its deadline to November 3, 2019.

Effective date: November 2, 2018

 

Quarterly Listing of Program Issuances--July Through September 2018

On November 2, CMS published a Notice in the Federal Register as it does each quarter listing all CMS manual instructions, substantive and interpretive regulations, and other notices published from July through September 2018.

 

Update to Medicare Deductible, Coinsurance, and Premium Rates for 2019

On November 2, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 119 regarding updates to the claims processing system with the new CY 2019 Medicare rates.

Effective date: January 1, 2019

Implementation date: January 7, 2019

 

Internet Only Manual (IOM) Updates to Pub. 100-01, 100-02, and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)

On November 2, CMS published Medicare Benefit Policy Transmittal 249 and Medicare General Information, Eligibility, and Entitlement Transmittal 120 regarding updates to Medicare manuals to correct various minor technical errors and omissions. There are no policy changes anticipated due to this update.

Effective date: December 4, 2018

Implementation date: December 4, 2018

 

Revision of Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edits for Ambulance Services Rendered to Beneficiaries in a Part A Stay

On November 2, CMS published One-Time Notification Transmittal 2176 regarding revisions to SNF CB edits to ensure accurate payment of ambulance services rendered to beneficiaries in a Part A stay.

Effective date: April 1, 2019

Implementation date: April 1, 2019

 

Hospital and Critical Access Hospital (CAH) Swing-Bed Manual Revisions and Shared Systems Changes

On November 2, CMS published Medicare Claims Processing Transmittal 4157 regarding policies related to hospitals and CAHs related to services furnished to swing-bed patients and policies related to pass-through reimbursement for certified registered nurse anesthetist services.

Effective date: April 1, 2019

Implementation date: April 1, 2019

 

Removal of the Provider Requirement for Reporting on an Institutional Claim a Value Code (VC) 05 - Professional Component-Split Implementation

On November 2, CMS published One-Time Notification Transmittal 2178 to remove any editing for the requirement of value code 05 on an institutional claim.

Effective date: April 1, 2019

Implementation date: April 1, 2019 - Analysis and Design; July 1, 2019 - Development and Implementation