This week in Medicare updates—10/30/2019
Medicare Quarterly Provider Compliance Newsletter
On October 21, CMS published the October issue of the Medicare Quarterly Compliance Newsletter. This edition of the newsletter contains reports on double payment for ambulance services subject to SNF Consolidated Billing requirements and claims for outpatient physical therapy that did not comply with Medicare billing requirements.
Requests for Information: Take Medicare Fraud, Waste, and Abuse Fighting Further Through Innovation
On October 21, CMS published two Requests for Information (RFI) on potential program integrity solutions. The Future of Program Integrity RFI seeks comments on new program integrity approaches in value-based programs and Medicare Advantage as well as ways to improve/utilize prior authorization and provider education in a more effective manner. The Advanced Technology in Program Integrity RFI seeks comments on how CMS can use artificial intelligence for tasks such as medical record review, ways documentation requirement repositories can be used efficiently and effectively, advanced technologies for Medicare Advantage and CMS contract-level risk adjustment data validation audits, and more.
Both RFIs are open until November 20.
Request for Nominations for Members for the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)
On October 21, CMS published a Notice in the Federal Register to announce its request for nominations for membership on MEDCAC. There will be 25 openings on MEDCAC as of June 2020: 18 for at-large standing MEDCAC membership, five for patient advocates, and two for industry representatives.
Nominations are due by Monday, November 18, 2019.
Trends in Nursing Home Complaints (2016-2018)
On October 22, the OIG published an Interactive Map to display details on nursing home complaint trends between 2016 and 2018. The map is part of the OIG’s continuous effort to analyze nursing home complaint and investigations data and trends.
Updated Civil Monetary Penalties and Affirmative Exclusions
On October 23, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following:
- On September 27, Dr. Ravi Goyal reached a $73,975 settlement agreement with the OIG to resolve allegations that Dr. Goyal submitted or caused to be submitted three invoices from a third party to his university, which is an NIH grantee, and had funds that the university paid to the third party flow to a company Dr. Goyal owned. Dr. Goyal did not disclose this to the university.
- On October 2, Physicians Group Services, P.A., reached a $1,128,615.04 settlement agreement with the OIG to resolve allegations that Physicians Group Services received remuneration from Millennium Health, LLC, f/k/a Millennium Laboratories, Inc., in the form of point of care test cups which resulted in prohibited referrals.
- On October 4, Ohio River Laboratories, LLC, of Houston, Texas, reached a $49,493.48 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for specimen validity testing, a noncovered service.
The list also included settlements reached with facilities who employed individuals they knew or should have known were excluded from participation in federal health care programs. These facilities include:
- Miller’s Health System, Inc., d/b/a Miller’s Merry Manor, of Portage, Indiana
- West Texas Multicare Clinic, P.A., d/b/a Precision Chiropractic, of Amarillo, Texas
Sunshine ACO, LLC, Generally Reported Complete and Accurate Data on Quality Measures Through the CMS Web Portal, But There Were a Few Reporting Deficiencies that Did Not Affect the Overall Quality Performance Score
On October 23, the OIG posted a Review of whether Sunshine ACO, LLC, complied with federal requirements when reporting data on quality measures through the CMS web portal. Incomplete or inaccurate data had the potential to affect shared savings payments. The OIG found that Sunshine complied with federal requirements for all but 11 sampled beneficiary-measures. Those 11 measures determined to be in error had medical records that either did not support inclusion in measure population or did not satisfy the conditions of the quality measures. These deficiencies, however, did not affect Sunshine’s overall quality performance score. The OIG did not provide any recommendations for Sunshine because Sunshine voluntarily terminated its participation in the Shared Savings Program effective May 31, 2019.
Billing Instructions for Beneficiaries Enrolled in Medicare Advantage Plans for Services Covered by Decision Memo CAG-00451N (CAR T-Cell Therapy)
On October 24, CMS published Special Edition MLN Matters 19024 regarding information about billing CAR T-cell therapy for beneficiaries enrolled in Medicare. Due to the nature of the NCD, fee-for-service Medicare will pay for CAR-T therapy obtained by beneficiaries enrolled in Medicare Advantage effective August 7, 2019. The article instructs providers on HCPCS codes and revenue codes to use when billing for these services and provides scenarios with further clarification on how to report items and services related to CAR-T.
Effective date: August 7, 2019
Implementation date: August 7, 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020
On October 25, CMS published Medicare Claims Processing Transmittal 4422 regarding the quarterly update to the NCCI PTP edits. The latest package will be available via the CMS Virtual Data Center on or about November 2, 2019.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Revisions to State Operations Manual (SOM) Appendix G, Guidance for Surveyors: Rural Health Clinics
On October 25, CMS published State Operations Provider Certification Transmittal 194 regarding updates to medical emergency guidance pertaining to the availability of drugs and biologicals commonly used in life-saving procedures. It states that not all categories of drugs/biologicals must be stored, but providers should consider community factors and patient histories when determining the availability of drugs/biologicals available for addressing life-threatening injuries and acute illnesses. RHCs also must have written policies and procedures to determine what they store for these purposes.
Effective date: October 25, 2019
Implementation date: October 25, 2019