This week in Medicare updates—5/1/19
Provider Compliance Tips for Ordering Lower Limb Orthoses
On April 22, CMS published an MLN Fact Sheet regarding denial prevention for lower limb orthoses. During the 2018 reporting period, the projected improper payment amount for lower limb orthoses was more than $235.2 million, and insufficient documentation errors accounted for 84.7% of reviewed improper payments. Coverage for these orthoses varies depending on joints involved and ambulation use, and CMS included the coverage requirements for each type of orthosis in the fact sheet.
Provider Compliance Tips for Ostomy Supplies
On April 22, CMS published an MLN Fact Sheet regarding compliance tips for billing ostomy supplies. During the 2018 reporting period, the projected improper payment amount for ostomy supplies was $92.4 million, and 81.6% of improper payments were due to insufficient documentation. The fact sheet describes the type of documentation necessary within the medical record to support medical necessity, information on the LCD (L33828) listing the HCPCS codes used to bill for these supplies, and types of supplies that are too similar to be provided/billed in unison. It also reminds providers that ostomy supplies are not separately payable when a beneficiary is in a covered home health episode and includes guidelines on refill requirements.
Update to the Required Prior Authorization List of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Items that Require Prior Authorization as a Condition of Payment
On April 22, CMS published an Update in the Federal Register regarding the addition of 12 HCPCS codes to the Required Prior Authorization List of DMEPOS Items.
Dates: Phase one of implementation is effective on July 22, 2019. Phase two of implementation is effective on October 21, 2019.
Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Items; Update to the Master List of Items Frequently Subject to Unnecessary Utilization
On April 22, CMS published Master List Additions in the Federal Register regarding the addition of four HCPCS codes to the Master List of Items Frequently Subject to Unnecessary Utilization that could potentially be subject to prior authorization as a condition of payment.
Effective date: May 22, 2019
Primary Care First: Foster Independence, Reward Outcomes
On April 22, CMS published a Press Release to announce a new set of payment models called the Primary Cares Initiative, which is aimed at supporting the delivery of advanced primary care. This set of voluntary five-year payment models is administered through two pathways: Primary Care First (divided into the general model and a high need population model) and Direct Contracting (divided into a global model, professional model, and geographic model). Participation in these models is anticipated to begin as early as January 2020.
CMS published fact sheets on the Primary Care First model options, Direct Contracting model options, and Primary Cares Initiative on the same date. CMS also published a Request for Information (RFI) on the Direct Contracting-Geographic Population-Based Payment Model on the same date. Comments on the RFI are due by May 23, 2019.
Medicare Trustees Report Shows Hospital Insurance Trust Fund Will Deplete in Seven Years
On April 22, CMS published a Press Release to announce the findings from the Medicare Board of Trustees’ Annual Report on the two Medicare trust funds. Like last year, the report found that the Hospital Insurance Trust Fund will only be able to pay full benefits until 2026. The report also projects that total Medicare costs will grow from approximately 3.7% of the GDP in 2018 to 5.9% of the GDP by 2038.
2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule
On April 23, CMS published a draft version of the 2020 IPPS and LTCH Proposed Rule. The rule contains significant proposals relevant to rural health payment, wage index methodology, and new technology, and it projects a 3.7% increase in IPPS payments. Some of the proposals in the rule include:
- Reducing the wage index disparity by increasing the wage index for certain low wage index hospitals and decreasing the wage index by a limited amount for some high wage index hospitals
- Changing the qualification criteria for new technology add-on payments, including revisions to the “substantial clinical improvement” criterion
- Continuing new technology add-on payments for two types of chimeric antigen receptor (CAR) T-cell therapy
- Increasing the new technology add-on payment from 50% to 65% beginning in 2020
CMS published a Press Release and Fact Sheet on the proposed rule on the same date. The rule is scheduled to be published in the Federal Register on May 3. Comments on proposals are due to CMS no later than 5 p.m. ET on June 24.
Extension of Comment Period: Interoperability and Patient Access Proposed Rule
On April 23, CMS published an Extension of Comment Period in the Federal Register regarding the Interoperability and Patient Access for Medicare Advantage proposed rule that was originally published in the Federal Register on March 4. The comment period has been extended by 30 days and will now end on June 3, 2019. CMS will also adjust the effective dates of policies proposed to allow for adequate implementation times following the extension.
CMS Announces New Opportunities to Test Innovative Integrated Care Models for Dually Eligible Individuals
On April 24, CMS published a Press Release regarding a Letter to State Medicaid Directors on innovative approaches to better serve dually eligible beneficiaries. Fewer than 10% of dually eligible individuals are enrolled in any form of care that integrates Medicare and Medicaid services, and one of CMS’ priorities for 2019 includes creating a more seamless experience for beneficiaries and providers across the two programs. CMS described three approaches for streamlining care, including a capitated financial alignment model, a managed fee-for-service model, and state-specific models.
Comment Request: Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration
On April 24, CMS published a Comment Request in the Federal Register regarding an information collection for OMB review titled, “Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration.” Comments on the information collection are due to the OMB desk officer by May 24, 2019.
Comment Request: Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a); Hospital Wage Index Occupational Mix Survey
On April 24, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a)
- Hospital Wage Index Occupational Mix Survey
Comments are due by June 24, 2019.
Updated Corporate Integrity Agreement Documents
On April 25, the OIG published information on two new Corporate Integrity Agreements, including:
- Astellas Pharma US, Inc., of Northbrook, IL
- Amgen Inc., of Thousand Oaks, CA
Updated Civil Monetary Penalties and Affirmative Exclusions
On April 26, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions with three settlements resulting from facilities who allegedly employed individuals they knew or should have known were excluded from participation in federal healthcare programs, including:
- Berea Alzheimer’s Care Center, of Berea, Ohio
- Sweeny Community Hospital d/b/a Lake Jackson Healthcare, of Lake Jackson, Texas
- Aroostook Mental Health Services, Inc., of Caribou, Maine
Updated Stipulated Penalties and Exclusion for Material Breach
On April 26, the OIG updated its list of Stipulated Penalties and Exclusion for Material Breaches with one new action:
- On April 23, Melissa Robitaille, D.P.M. and Atlantic Foot and Ankle Specialists, P.C., paid a stipulated penalty of $16,500 based on the late submission of their quarterly claims review report.
Documentation of Evaluation and Management Services of Teaching Physicians
On April 26, CMS published Medicare Claims Processing Transmittal 4283 to clarify language in the manual regarding documentation of teaching physicians either performing services or being physically present during a service and the extent to which the teaching physician participates in direction or review of services.
Effective date: January 1, 2019
Implementation date: July 29, 2019
Quarterly Update to the End-Stage Renal Disease (ESRD) Prospective Payment System
On April 26, CMS published Medicare Claims Processing Transmittal 4285 regarding instructions for new codes added to the HCPCS file and the list of items and services subject to the ESRD PPS consolidated billing requirements. New additions include a new code for anemia management, J1444, which should be accompanied by the JE modifier, as the injection is administered via dialysate.
Effective date: July 1, 2019
Implementation date: July 1, 2019