This week in Medicare updates—1/2/2019
Payments Made by National Government Services, Inc., to Hospitals for Certain Advanced Radiation Therapy Services Did Not Fully Comply With Medicare Requirements
On December 17, the OIG published a Review of whether NGS appropriately paid hospitals for selected outpatient claims in compliance with Medicare requirements for intensity-modulated radiation therapy (IMRT). The OIG found that NGS made overpayments to hospitals for at least one service for 99% of beneficiaries included in the random sample. These overpayments occurred due to system edits inadequately preventing payments by NGS to hospitals for incorrectly billed IMRT services and due to hospitals who were unfamiliar with or misinterpreted Medicare guidance regarding billing for these services.
The OIG made three recommendations to NGS in regard to recovering the overpayments and made two procedural recommendations to implement payment edits and educate hospitals on proper billing for IMRT services. In its response, NGS took issue with the OIG’s characterization of its role in how Medicare claims are processed and paid, and NGS asserted that it was inaccurately attributed responsibility for implementing and maintaining NCCI edits. The OIG revised the report language to clarify NGS’s role in claims processing, but the OIG maintained that its findings, estimates, and recommendations within the report were valid.
Request for Nominations to the Advisory Panel on Outreach and Education (APOE)
On December 17, CMS published a Notice in the Federal Register to request nominations for individuals to serve on the APOE. Nominations will be considered if they are received no later than 5 p.m. on January 16, 2019.
What Suppliers Need to Know About Orders for DMEPOS Items
On December 18, CMS published Special Edition MLN Matters 18009 regarding information about orders for DMEPOS items. The article reviews what constitutes a detailed written order, which items require an order before delivery, and how to manage orders from telemarketers and telemedicine companies.
Final Rule: Medicare Shared Savings Program; Accountable Care Organizations--Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017
On December 21, CMS published a Final Rule regarding the Medicare Shared Savings Program and a new direction for Medicare Accountable Care Organizations (ACO). This direction, Pathways to Success, will redesign participation in the program to encourage ACOs to transition to performance-based risk quicker and to address additional tools and flexibilities for ACOs finalized in the Bipartisan Budget Act of 2018.
CMS published a Press Release and Fact Sheet on the program on the same date. The rule will be effective 45 days after it is published in the Federal Register, which is scheduled for December 31, 2019.
Update to Chapter 12 (The Comprehensive Error Rate Testing [CERT] Program) of the Medicare Program Integrity Manual
On December 21, CMS published Medicare Program Integrity Transmittal 852 regarding updates to Chapter 12 of the Program Integrity Manual. Some of these updates include reformatted section numbers, additional MAC instructions for claims canceled after the date of the CERT transaction file, and the removal of the section on CERT program treatment of power mobility device and repetitive scheduled non-emergent ambulance transport claims in the prior authorization model.
Effective date: January 24, 2019
Implementation date: January 24, 2019
January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0
On December 21, CMS published Medicare Claims Processing Transmittal 4185 regarding the instructions and specifications for the January 1, 2019 update to the I/OCE.
On December 26, CMS published MLN Matters 11068 to accompany the transmittal.
Effective date: January 1, 2019
Implementation date: January 7, 2019
Provider Reimbursement Manual - Part 1, Chapter 28, Prospective Payments
On December 21, CMS published Provider Reimbursement Manual Transmittal 279 regarding revisions to Section 2810 in the manual to clarify guidance on the special treatment of sole community hospitals (SCH) for cost reporting periods beginning prior to January 1, 2009, and for cost reporting periods beginning on or after January 1, 2009. The section also includes revisions to guidance on special treatment of SCHs for cost reporting periods beginning on or after October 1, 2017.
Effective date: N/A
Additional Documentation Limits for Medicare Institutional Providers
On December 21, CMS published a Updated Document regarding the additional documentation request (ADR) limits for providers. The update changes the ADR cycle limit from zero to one for providers who, under the previous methodology, would have had an ADR cycle of zero even though their annual ADR limit was greater than zero.
New Search Features Added to Fiscal Intermediary Shared System (FISS)/Direct Data Entry (DDE)
On December 21, CMS published Special Edition MLN Matters 18028 regarding two new features that are being added to the FISS/DDE inquiries menu options in January 2019. These features include a translator tool as well as an option to search for a claim using the FISS Document Control Number (DCN).
Effective date: N/A
Implementation date: N/A
Extension of the Designation of the Current Nursing Shortage as an “Extraordinary Circumstance” per 42 CFR 418.64, Core Services
On December 21, CMS published a Memorandum to state survey agency directors regarding nursing shortages in hospices. The memo announces the extension of CMS’ designation of the national nursing shortage as an extraordinary circumstance for an additional two years in order to enable hospice agencies which are unable to provide sufficient nursing staff due to the shortage to utilize contracted staff in addition to the full-time nursing staff. CMS is also eliminating the requirement for the hospice agency to notify CMS of its use of contracted staff during extraordinary circumstances.
Effective date: Immediately. These guidelines should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of the memorandum.
First Coast Service Options, Inc., Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements
On December 27, the OIG published a Review of whether First Coast Service Options, Inc., appropriately paid for hyperbaric oxygen (HBO) therapy services in accordance with Medicare requirements. The OIG found that First Coast made payments for HBO therapy services that did not comply with Medicare requirements for 110 of the 120 claims reviewed during the audit. These overpayments occurred because First Coast did not have effective automated Part A prepayment edits in place during the audit period. The OIG estimates that First Coast inappropriately overpaid providers $39.7 million during this time.
The OIG recommended First Coast recover any identified overpayments during and after the audit period and work with CMS in developing more effective automated HBO therapy prepayment edits. First Coast concurred with most of the OIG’s recommendations but questioned language stating that it did not have automated Part A prepayment edits in its claims processing system to monitor HBO therapy. The OIG revised its report language to say that while First Coast’s Part A prepayment edits were active in the processing system, those edits were not effective in the prevention of improper payments for HBO therapy.
Correction Notice: Durable Medical Equipment and End Stage Renal Disease Final Rule
On December 28, CMS published a Correction Notice in the Federal Register to correct technical and typographical errors that appeared in the Durable Medical Equipment and End Stage Renal Disease final rule, published November 14, 2018. These corrections mainly consist of changing a handful of typographical errors referring to the final rule instead of the proposed rule.
Effective date: This correction is effective on January 1, 2019.
Correction Notice: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems Final Rule
On December 28, CMS published a Correction Notice in the Federal Register to correct technical and typographical errors from the OPPS and ASC final rule. These corrections include updates to inadvertently transposed HCPCS code numbers, updated effective dates for certain HCPCS codes, a corrected wage index adjustment for ASCs, and more.
Dates: The corrections in this document are effective January 1, 2019.
Clarification of Part B Recovery Audit Contractor (RAC) Appeals Case File Sharing Process
On December 28, CMS published One-Time Notification Transmittal 2216 to clarify the Part B appeals case file sharing process as outlined in CR 10369. This correspondence should be shared by the MCS on the daily report but adjustments shall not.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Ensuring Only the Active Billing Hospice Can Submit a Revocation
On December 28, CMS published Medicare Claims Processing Transmittal 4187 regarding a new Common Working File edit to ensure that the provider identifier on Type of Bill (8xB) matches the most recent provider identifier on a hospice benefit period.
Effective date: July 1, 2019 - Claims received on or after this date
Implementation date: July 1, 2019
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements
On December 28, CMS published Medicare Claims Processing Transmittal 4188 to update the Internet Only Manual language pertaining to the National Correct Coding Initiative (NCCI), Chapter 23 - Fee Schedule Administration and Coding Requirements.
Effective date: January 30, 2019
Implementation date: January 30, 2019