This week in Medicare updates—12/5/2018
Comment Request: Notice of Research Exception under the Genetic Information Nondiscrimination Act; Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Affordable Insurance Exchanges, Medicaid and Children’s Health Insurance Program Agencies; more
On November 26, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Notice of Research Exception under the Genetic Information Nondiscrimination Act
- Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Affordable Insurance Exchanges, Medicaid and Children’s Health Insurance Program Agencies
- State-based Exchange Annual Report Tool (SMART)
Comments on these information collections are due by January 25, 2019.
Proposed Rule: Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses
On November 26, CMS published a Proposed Rule regarding changes to the Medicare Advantage program regulations and Prescription Drug Benefit program to allow for increased negotiation of lower drug prices and reduce out-of-pocket costs for Part C and Part D enrollees. The proposed policies include implementing broader use of prior authorization and step therapy, allowing exclusions for protected classes of drugs from formularies under specific conditions, increased utilization of electronic real time benefit tools, and more.
CMS published a Press Release and Fact Sheet on the proposed rule on the same date. Comments on the proposed rule are due no later than 5 p.m. on January 25, 2019.
New Online Tool Displays Cost Differences for Certain Surgical Procedures
On November 27, CMS published a Press Release regarding a new online tool that allows customers to compare national averages of Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. This tool is launching to fulfill a requirement from the 21st Century Cures Act.
Comment Request: Home Health Change of Care Notice
On November 27, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Home Health Change of Care Notice.” Comments are due by January 28, 2019.
The 2018 Merit-based Incentive Payment System (MIPS) Automatic Extreme and Uncontrollable Circumstances Policy
On November 27, CMS published a Fact Sheet regarding the automatic extreme and uncontrollable circumstances policy. In the CY 2019 Physician Fee Schedule final rule, CMS finalized the automatically reweighted performance categories for MIPS-eligible clinicians affected by an extreme and uncontrollable event. The fact sheet explains situations in which this policy does and does not apply, and it walks through some frequently asked questions related to this policy.
Significant Vulnerabilities Exist in the Hospital Wage Index System for Medicare Payments
On November 27, the OIG published a Review of hospital wage data to determine the extent of any vulnerabilities within the hospital wage index system. The OIG determined that the following significant vulnerabilities exist:
- Lack of CMS authority to penalize hospitals—absent misrepresentation or falsification—for submitting inaccurate or incomplete wage data
- MAC limited reviews do not always identify inaccurate wage data
- The rural floor decreases wage index accuracy
- Hold-harmless provisions in federal law and CMS policy pertaining to geographically reclassified hospitals’ wage data decrease wage index accuracy
Because of these vulnerabilities, wage indexes may not accurately reflect local labor prices, meaning Medicare payments to hospitals and other providers may not be appropriately adjusted to reflect local labor prices. The OIG issued six recommendations detailed within the report to help boost wage index accuracy.
Updated Corporate Integrity Agreement Documents
On November 28, the OIG published information on a new Corporate Integrity Agreement with Howard Stark Professional Pharmacy, Inc., d/b/a Stark Pharmacy, Gary Gray, and Steven J. Schafer, of Overland Park, Kansas.
New Medicare Webpage on Patient Driven Payment Model
On November 28, CMS published Special Edition MLN Matters 18026 regarding the new Patient Driven Payment Model (PDPM) webpage available to SNFs. The article contains a summary of the new resources now available on that webpage.
Effective date: N/A
Implementation date: N/A
Next Generation Accountable Care Organization (NGACO) Model Post Discharge Home Visit HCPCS
On November 28, CMS published Demonstrations Transmittal 215, which rescinds and replaces Transmittal 213, dated October 26, 2018, to replace the set of billing codes in BRs 10907.1, 10907.1.1, 10907.1.2, 10907.1.3, 10907.1.4, 10907.1.5, 10907.1.8, and 10907.1.9). The original transmittal was issued to implement new HCPCS codes for the Post Discharge Home Visit Waiver.
On November 29, CMS published a revised MLN Matters 10907 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: April 1, 2019
Targeted Probe and Educate
On November 28, CMS published One-Time Notification Transmittal 2207, which rescinds and replaces Transmittal 1919, dated September 15, 2017, to clarify language in BR 10249.8 to more accurately reflect that the new review probe must be for services/items furnished 45 days after the 1:1 education, and not just the submission date of the claim (except for long services related to home health and hospices). The original transmittal was issued regarding the expansion of existing Targeted Probe and Educate (TPE) Pilot to include all Medicare Administrative Contractors (MAC).
Effective date: October 1, 2017
Implementation date: No later than October 1, 2017
Comment Request: Solicitation for Applications for Medicare Prescription Drug Plan 2020 Contracts; Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention
On November 29, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Solicitation for Applications for Medicare Prescription Drug Plan 2020 Contracts
- Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention
Comments are due to the OMB desk officer by December 31, 2018.
Correction: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs
On November 30, CMS published a Correction in the Federal Register to the OPPS Final Rule to correct the public comment period end date to January 2, 2019.
Effective date: This correction is effective November 29, 2018.
Comment period: To be assured consideration, comments on the payment classifications assigned to the interim APC assignments and/or status indicators of new or replacement Level II HCPCS codes in FR Doc. 2018–24243 of November 21, 2018 (83 FR 58818), must be received at one of the addresses provided in the ADDRESSES section no later than 5 p.m. EST on January 2, 2019.
Comment Request: Data Request and Attestation for PDP Sponsors
On November 30, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Data Request and Attestation for PDP Sponsors.” Comments on the information collection are due by January 29, 2019.
Request for Nominations for Members for the Medicare Evidence Development & Coverage Advisory Committee
On November 30, CMS published a Notice in the Federal Register to announce the request for nominations for membership on the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). Nominations must be received by Monday, January 7, 2019.
Payroll Based Journal (PBJ) Policy Manual Updates, Notification to States and New Minimum Data Set (MDS) Census Reports
On November 30, CMS published a Memorandum to state survey agency directors regarding staffing data for nursing homes. CMS will provide regional offices and state survey agencies with a list of facilities with potential staffing issues to support survey activities for evaluating sufficient staffing and improving resident health and safety. CMS is also expanding guidance in the PBJ Policy Manual to expand guidance on meal breaks in order to ensure consistency. CMS will also add guidance regarding reporting hours for “Universal Care Workers.” CMS is also creating two new MDS-based census reports in the Certification and Survey Provider Enhanced Reporting (CASPER) system.
CMS published a Press Release on these initiatives on the same date.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the State/Regional Office training coordinators within 30 days of this memorandum.
CMS’s Enhanced Controls Did Not Always Prevent Terminated Drug Utilization in Medicare Part D
On November 30, the OIG published a Review of whether steps CMS has taken to address terminated drug utilization in Medicare Part D were effective and to determine whether prescription drug event (PDE) data for terminated drugs continued to be accepted in CYs 2014 and 2015. The review found that CMS was not entirely effective in preventing terminated drug utilization, as it accepted PDE data totaling $31.9 million in gross drug costs for 3,705 terminated drugs in CYs 2014 and 2015. The OIG also found that the NSDE file termination dates and quarterly Medicaid drug rebate files termination dates by National Drug Code (NDC) did not match, and CMS did not compare the information in these two files, investigate discrepancies, or update its system edits in a timely manner.
The OIG recommends CMS work with the FDA to verify the accuracy of drug termination dates, compare the information on termination dates in its two data sources, investigate discrepancies between data sources, and verify termination dates with the manufacturers. The OIG also recommends CMS update its system edits with a new NSDE file on a more timely basis. CMS did not concur with the recommendation to work with the FDA to strengthen internal controls to ensure PDE data for terminated drugs are rejected as it does not believe it is administratively feasible to investigate and address discrepancies in information between the Medicaid drug rebate files and the FDA’s NSDE file.
Fall 2018 Semiannual Report to Congress
On November 30, the OIG published its Fall 2018 Semiannual Report to Congress detailing the most significant work performed by the OIG and the Department of Health and Human Services for the April 1, 2018 to September 30, 2018 reporting period.
Annual Update to the Per-Beneficiary Therapy Amounts
On November 30, CMS published Medicare Claims Processing Transmittal 4178 to describe the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 was signed into law.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
On November 30, CMS published Medicare Claims Processing Transmittal 4176 regarding the implementation of policies in the CY 2019 MPFS final rule and announces the telehealth originating site facility fee payment amount.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.0 Effective January 1, 2019
On November 30, CMS published Medicare Claims Processing Transmittal 4175 regarding the quarterly update to the NCCI PTP edits.
CMS published MLN Matters 11044 on the same date to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke
On November 30, CMS published Medicare Benefit Policy Transmittal 251 and Medicare Claims Processing Transmittal 4173 regarding revisions to the definition of the personal supervision of the physician supervision of diagnostic procedures indicator to specify that procedures performed by a registered radiologist assistant or a radiology practitioner assistant may be performed under direct supervision.
Effective date: January 1, 2019
Implementation date: January 2, 2019
National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)
On November 30, CMS published National Coverage Determinations Transmittal 210 to notify contractors that, effective March 16, 2018, CMS will cover diagnostic lab tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.
Effective date: March 16, 2018
Implementation date: March 8, 2019—A/B MACs
Ambulance Inflation Factor for Calendar Year 2019 and Productivity Adjustment
On November 30, CMS published Medicare Claims Processing Transmittal 4172 regarding the calendar year 2019 ambulance inflation factor for determining the payment limit for ambulance services.
CMS published MLN Matters 11031 on the same date to accompany the transmittal.