This week in Medicare updates—6/12/2019
Spring Semiannual Report to Congress
On June 3, the OIG published its spring Semiannual Report to Congress, which covers OIG topics from October 1, 2018 through March 31, 2019. The report provides highlights of the OIG’s achievements during that time and discusses some of the key investigative actions into HHS programs such as Medicare over that six-month span.
State Operations Manual (SOM) Emergency Medical Treatment and Labor Act (EMTALA) and Death Associated With Restraint or Seclusion Complaint Investigation Timeline Revisions
On June 4, CMS published a Memorandum to state survey agency directors regarding changes to timelines for onsite complaint investigations for EMTALA complaints and surveys of death in restraint or seclusion in hospitals and critical access hospitals (CAH). To bring these types of investigations in line with other immediate jeopardy investigations, CMS will now require surveyors to be onsite to initiate an investigation within two business days.
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 the memorandum.
Comment Request: Medicare Coverage of Items and Services for Coverage with Evidence Development
On June 4, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Medicare Coverage of Items and Services for Coverage with Evidence Development.” Comments are due by August 5, 2019.
Announcement of the Annual Advisory Panel on Hospital Outpatient Payment (HOP) Panel Meeting in August 2019 and New Panel Members
On June 5, CMS published a Notice in the Federal Register to announce the dates of the 2019 HOP Panel meeting and to propose six new membership appointments to the panel. The meeting will be held Monday, August 19, 2019, from 9:30 a.m. to 5:00 p.m. ET and Tuesday, August 20, 2019, from 9:30 a.m. to 12:00 p.m. ET at CMS. The notice also includes a list of six new members who were appointed to the panel for terms beginning March 1, 2019, and ending February 28, 2023.
Updated List of Excluded Individuals and Entities (LEIE)
On June 5, the OIG updated its LEIE with an updated LEIE database for download and lists of May 2019 exclusions, reinstatements, and profile corrections.
St. Joseph’s Hospital and Medical Center Submitted Some Inaccurate Wage Data
On June 5, the OIG published a Review of whether St. Joseph’s Hospital and Medical Center, of Phoenix, Arizona, complied with Medicare requirements for reporting wage data to be used in CMS’ calculations of hospital wage indexes for FY 2019. The OIG found St. Joseph’s did not always comply with Medicare requirements and overstated its hours by 31,827 and its wages and wage-related costs by $12,338,804. Because St. Joseph’s applied to be considered a rural hospital for wage index purposes, the hospital’s data contributes to the Arizona rural wage index for FY 2019. These overstated hours and wage data would have inaccurately raised the rural wage index from 1.0528 to 1.0627, leading to a potential $11.6 million in overpayments for inpatient stays at the 54 Arizona hospitals receiving the rural wage index or the benefit of rural floor wage index in FY 2019.
The OIG stated St. Joseph’s errors occurred because it reassigned assembly and reporting of wage data to a new staff group, did not have adequate review procedures to ensure that dollars and hours were reported correctly on the wage data worksheet, and did not have adequate quality control over the entry of contract labor data into its accounting system. The OIG contacted CMS and the hospital’s MAC to report its findings and suggested corrections so the MAC could make the appropriate corrections. The OIG also recommends St. Joseph’s ensure all personnel involved in the wage data reporting process are adequately trained in Medicare compliance requirements, review all software scripts and manual procedures related to this reporting process annually, and implement more effective quality controls over contract labor data in its accounting system.
Request for Information: Reducing Administrative Burden to Put Patients over Paperwork
On June 6, CMS published a draft version of a Request for Information (RFI) regarding the Patients over Paperwork initiative. CMS is seeking additional input from providers on ways to reduce burden related to coding documentation requirements, reporting documentation requirements, prior authorization procedures, policies and requirements for rural health, beneficiary enrollment and eligibility determination, and more.
CMS published a Press Release regarding the RFI on the same date. The RFI is scheduled to be published in the Federal Register on June 11. Comments are due by August 12, 2019.
Explanation of Federal Fiscal Year (FY) 2004, 2005, and 2006 Outlier Fixed-Loss Thresholds as Required by Court Rulings
On June 6, CMS published a Clarification in the Federal Register to provide additional explanations for the outlier fixed-loss thresholds (FLT) from 2004, 2005, and 2006. A court ruling in 2015 determined that the 2004 IPPS final rule did not adequately explain the handling of data pertaining to 123 hospitals CMS had identified as likely to have been turbocharging, and a separate court ruling in 2015 required CMS to provide an additional explanation of the FLT from the 2004 final rule explaining why CMS did not exclude that alleged turbocharged data. While CMS published an initial explanation for this in the January 22, 2016 Federal Register, a new court case about the matter, Banner Health v. Price, led the district court to issue a new remand order on April 12, 2018, as the court ruled CMS still had not adequately explained the inclusion of this data and adjustments to cost-to-charge ratios to simulate updates when more recent cost reports are tentatively settled.
Great Lakes Home Health Services, Inc., Billed for Home Health Services That Did Not Comply with Medicare Coverage and Payment Requirements
On June 6, the OIG published a Review of whether Great Lakes Home Health Services, Inc., complied with Medicare home health billing requirements. The OIG found that Great Lakes did not comply with billing requirements for 38 of the 100 home health claims reviewed, and it received overpayments of $64,114 for services provided during CYs 2014 and 2015. These errors related to beneficiaries whom the OIG determined were not homebound and did not require skilled services.
Great Lakes generally disagreed with all of the OIG’s findings. It stated that the OIG’s original report confused the distinctions between physical and occupational therapists with the services provided by home caregivers. In the two sample items highlighted by Great Lakes as confusing the distinction between physical and occupational therapists, the OIG agreed with Great Lakes and reversed its findings. The OIG also reversed its findings on all six claims identified as having incorrect HIPPS codes. The OIG determined those claims were incorrectly identified due to a software error in its home health grouper program. In total, the OIG reversed its findings on 21 of 59 claims cited in the draft report as claims filed in error.
Correction: Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, PACE, Medicaid Fee-for-Service, and Medicaid Managed Care Programs for Years 2020 and 2021
On June 7, CMS published a Correction in the Federal Register regarding technical and typographical errors from the Policy and Technical Changes to Medicare Advantage, Medicare PDB, PACE, Medicaid Fee-for-Service, and Medicaid Managed Care Programs final rule, dated April 16, 2019. These corrections include citation errors, incorrect dates, typographical errors, and more.
Effective date: The corrections to the preamble of the final rule are effective June 7, 2019. The correction in instruction 8 is effective June 17, 2019. The corrections in instructions 5, 6, 7, and 9 are effective January 1, 2020. The correction in instruction 4 is effective January 1, 2021.
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) EFT: Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of CARCs, RARCs, and CAGC Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE
On June 7, CMS published Medicare Claims Processing Transmittal 4317 regarding instructions to the contractors and shared system maintainers to update systems based on the CORE 360 Uniform use of CARC, RARC, and CAGC rule publication.
Effective date: October 1, 2019
Implementation date: October 7, 2019