This week in Medicare updates—4/22/2020
An Estimated 87% of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements
On April 13, CMS published a Review of whether IPFs complied with Medicare coverage, payment, and participation requirements for services in FYs 2014 and 2015 that resulted in outlier payments. The OIG found that 25 of the 160 sampled claims did not meet medical necessity requirements and 142 of the 160 sampled claims had missing or inadequate medical record elements. This included 115 claims that did not meet Medicare physician certification requirements. The OIG also identified three areas of concern: (1) outlier payments made for stays that were not unusually costly, (2) beneficiaries using lifetime reserve days for days when they no longer needed inpatient hospitalization but could not find an available and appropriate post-hospitalization placement, and (3) CMS not tracking patient falls or fall rates at IPFs. Overall, the OIG estimated that 87% of IPF claims for the audit period did not meet Medicare medical necessity or medical record requirements.
The OIG recommends increasing post-payment reviews to provide more feedback to IPFs, promulgating regulations on patient rights to make informed decisions regarding care, studying the accuracy of the outlier payment methodology, tracking patient falls or fall rates, researching whether physician certification requirements are useful in preventing inappropriate payments, require a specific format for certifications to aid in auditing, and studying issues related to lifetime reserve day use.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 3rd Qtr Notification for FY 2020
On April 13, CMS published Medicare Financial Management Transmittal 10049 regarding the normal quarterly interest rate update for overpayments and underpayments. The new private consumer rate has been changed to 9.625%.
Effective date: April 20, 2020
Implementation date: April 20, 2020
CMS Removes Non-Invasive Ventilators from Round 2021 of the Competitive Bidding Program
On April 13, CMS published a Notice to announce that it is removing the non-invasive ventilators product category from Round 2021 of the DMEPOS Competitive Bidding Program due to the COVID-19 pandemic. Due to this action, any Medicare-enrolled DMEPOS supplier can furnish any type of ventilator covered under Medicare.
COVID-19 Long-Term Care Facility Transfer Scenarios
On April 13, CMS published a Memorandum to state survey agency directors regarding information on transferring or discharging residents between facilities depending on COVID-19 status. The memo states that while long-term care facilities should continue to work with state and local leaders to determine ways to coordinate appropriate relocation of residents, CMS has issued certain blanket waivers relaxing requirements for LTC facilities that would ease issues related to transfers and housing specifications. CMS is also providing supplemental guidance on this process through the memorandum.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/branch training coordinators within 30 days of the memo.
Postponement of 2019 Benefit Year HHS-Operated Risk Adjustment Data Validation (HHS-RADV)
On April 13, CMS published a Notice regarding the postponement of the 2019 HHS-RADV process. Due to issues related to COVID-19, CMS will be postponing the issuance of the 2019 HHS-RADV enrollee samples, which had been scheduled for late May 2020, indefinitely, and as such, it is exercising enforcement discretion to postpone issuer requirements related to the 2019 benefit year. CMS intends to provide further guidance by August 2020.
April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
On April 13, CMS published Medicare Claims Processing Transmittal 10046, which rescinds and replaces Transmittal 4545, dated March 13, 2020, to add information of the correction to Q4206 to the policy section. The original transmittal was issued regarding the April 2020 ASC payment system update.
CMS revised MLN Matters 11694 on April 14 to accompany the transmittal.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Medicare Home Health Agency Provider Compliance Audit: Residential Home Health
On April 14, the OIG published a Review of whether Residential Home Health complied with Medicare requirements for billing home health services on selected types of claims. The OIG found that Residential did not comply with Medicare billing requirements on 11 of the 100 claims reviewed. The errors were related to beneficiaries who were not homebound or did not require skilled services. The OIG estimated that Residential received overpayments of $16,927 for these claims.
The OIG recommends Residential identify and return any overpayments in accordance with the 60-day rule and strengthen its procedures to ensure homebound statuses are verified, documented, and continually monitored. It also recommends Residential strengthen procedures to ensure beneficiaries are receiving only reasonable and necessary skilled services. Residential disagreed with the OIG findings and recommendations and stated it plans to contest the findings through the appeals process.
Medicare Increases Payment for High-Production Coronavirus Lab Tests
On April 15, CMS published an Announcement regarding payment for high-production COVID-19 lab tests. CMS is increasing payment for high throughput technology lab tests reported by HCPCS codes U0003 or U0004 to $100 to reflect the more expensive technology and training required by these tests. This higher payment will be effective April 14, 2020 through the duration of the COVID-19 national emergency.
CMS published a Press Release on the announcement on the same date.
Updated OIG Work Plan
On April 15, the OIG updated its Work Plan with the following new items:
- Audit of HHS’s Production and Distribution of COVID-19 Lab Test Kits
- Opioid Use in Medicare Part D in 2019
New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCH), and Inpatient Rehabilitation Facilities (IRF) due to Provisions of CARES Act
On April 15, CMS published Special Edition MLN Matters 20015 regarding provisions of the CARES ACT which apply to IPPS hospitals, LTCHs, and IRFs. Some of these provisions include raising the weighting factor of DRGs by 20% for patients diagnosed with COVID-19, waiving the 15-hour therapy requirement per week for IRFs, and waiving certain site-neutral payment rate provisions for LTCHs.
FY 2021 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS)
On April 16, CMS published a draft copy of the 2021 IRF PPS Proposed Rule, which is scheduled to be published in the Federal Register on April 21. CMS proposes updating the IRF PPS total payments by 2.9% for FY 2021 and proposes adopting the most recent OMB statistical area delineations while also applying a 5% cap on wage index decreases from 2020 to 2021. Other proposals include allowing non-physician practitioners to perform any IRF coverage service and documentation duties currently required to be performed by a rehabilitation physician, no longer requiring a post-admission physician evaluation within the first 24 hours of admission, and codifying existing documentation instructions and guidance.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due no later than 5 p.m. on June 15.
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1
On April 16, CMS published Medicare Claims Processing Transmittal 10053, which rescinds and replaces Transmittal 10027, dated April 1, 2020, to revise both the summary of changes and summary of modifications attachments. The original transmittal was issued regarding the April updates to the I/OCE.
On April 16, CMS revised MLN Matters 11680 to accompany the transmittal.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Updated Corporate Integrity Agreement Documents
On April 17, the OIG published information on new Corporate Integrity Agreements with:
- Encore Rehabilitation Services, LLC, of Farmington Hills, MI
- Saber Healthcare Holdings, LLC (SHH) and more, of Bedford Heights, OH
- Casey, Christopher K. and Mead Square Pharmacy, Inc., of Williamsville, NY
New and Expanded Flexibilities for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) During the COVID-19 Public Health Emergency
On April 17, CMS published Special Edition MLN Matters 20016 regarding information for RHCs and FQHCs on flexibilities during the COVID-19 pandemic. The article discusses topics such as payment for telehealth services, the expansion of virtual communication services, revisions to requirements for providing visiting nursing services, consent for care management and virtual communication services, and more.