This week in Medicare updates—8/19/2020
COVID-19 FAQs on Medicare Fee-for-Service Billing
On August 7, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. This round of updates included information on whether condition code 44 applies while the utilization review Condition of Participation at 42 CFR 482.30 is waived.
CMS continues to update this document on a regular basis. Providers should review frequently for new information.
Announcement of the Advisory Panel on Hospital Outpatient Payment (HOP) Meeting
On August 10, CMS published a Notice in the Federal Register to announce the HOP Panel’s 2020 meeting will be held virtually on August 31 from 9 a.m. to 5 p.m. ET. The notice also announces the appointment of four new members to the panel. Attendees do not need to pre-register for the meeting.
Comment Request: Retiree Drug Subsidy (RDS) Application and Instructions; Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biologicals; more
On August 10, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:
- Retiree Drug Subsidy (RDS) Application and Instructions
- Retiree Drug Subsidy Payment Request and Instructions
- Manufacturer Submission of Average Sales Price (ASP) Data for Medicare Part B Drugs and Biologicals
- Consumer Experience Survey Data Collection
Comments are due to the OMB desk officer by September 9, 2020.
Desoto Home Health Care, Inc.: Audit of Medicare Payments for Orthotic Braces
On August 10, the OIG published a Review of whether Desoto Home Health Care, Inc., complied with Medicare requirements for proving medical necessity when billing for orthotic braces. The OIG found that, for all 100 sampled beneficiaries included in the review, Desoto did not meet Medicare’s medical necessity standards, leading to an estimated $2.8 million in unallowable Medicare payments for orthotic braces. The OIG recommends Desoto refund the DME MAC for the overpayments, identify and return any similar overpayments, and obtain as much information from beneficiary medical records as necessary to ensure claims for orthotic braces meet medical necessity requirements. Desoto stated that the OIG recommendations for a refund were not appropriate, findings were not accurately reflective of data, there were preliminary conclusions that did not match the independent medical review contractor’s later conclusions, and that it worked only with a beneficiary’s primary care doctor and furnished products to the beneficiary under that doctor’s medical supervision. The OIG maintained its original findings and recommendations and stated its methods for the review were appropriate.
Community Health Access and Rural Transformation (CHART) Model
On August 11, CMS published a Press Release and Fact Sheet to announce a new Innovation Center model, the Community Health Access and Rural Transformation (CHART) Model. The model seeks to address disparities in care for rural communities by increasing financial stability through new reimbursement methods, removing regulatory burdens to allow for increased operational and regulatory flexibility for rural providers, and offering additional services to address social determinants of health involving access to food and housing. CMS is offering two methods of participation in this program--the Community Transformation Track (first performance period beginning in July 2022) and the ACO Transformation Track (first performance period beginning January 2022).
More information on the model is available on the CHART Model webpage.
OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs
On August 11, the OIG published its Annual Report on the top unimplemented OIG recommendations for HHS to consider to reduce fraud, waste, and abuse. Of the top 25 recommendations for HHS department-wide, 10 recommendations pertain specifically to Medicare programs, and an additional general recommendation (HHS should develop department-wide objectives and a strategic framework for responding to international public health emergencies) could involve Medicare. Some of the Medicare-related recommendations involved reevaluating the inpatient rehabilitation facility payment system, comprehensively reforming the hospital wage index system, and implementing least costly alternative policies for Part B drugs.
Medicare Home Health Agency Provider Compliance Audit: Condado Home Care Program, Inc.
On August 12, the OIG published a Review of whether Condado Home Care Program, Inc., complied with Medicare requirements for billing home health services. The OIG found that Condado billed Medicare incorrectly for 14 of the 100 home health claims reviewed. These issues pertained to services provided to beneficiaries who did not require skilled services, services provided to beneficiaries who were not homebound, incorrect HIPPS payment codes, or services provided under a plan of care that did not meet Medicare requirements. The OIG estimated that Condado received at least $97,210 in overpayments for the audit period. The OIG recommends Condado refund Medicare for the identified overpayments and identify and return any similar overpayments. Condado responded with a list of corrective actions it has taken to address the OIG’s findings.
Visionquest Industries, Inc.: Audit of Medicare Payments for Orthotic Braces
On August 12, the OIG published a Review of whether Visionquest Industries, Inc., complied with Medicare requirements for proving medical necessity when billing for orthotic braces. The OIG found that, for 67 of the 100 sampled beneficiaries included in the review, Visionquest did not meet Medicare’s medical necessity standards, leading to an estimated $2.5 million in unallowable Medicare payments for orthotic braces. The OIG recommends Visionquest refund the DME MAC for the overpayments, identify and return any similar overpayments, and obtain as much information from beneficiary medical records as necessary to ensure claims for orthotic braces meet medical necessity requirements. Visionquest stated that the OIG review misapplied Medicare coverage criteria and disregarded evidence in medical records provided by Visionquest. It requested that the medical reviewer re-review the sampled beneficiaries’ unallowable claims, and upon further review, the OIG revised its report down from an original finding of 87 claims that did not comply with Medicare requirements to the 67 claims remaining in the final OIG report.
Proposed Decision Memo: Artificial Hearts and Related Devices, Including Ventricular Assist Devices (VAD) for Bridge-to-Transplant and Destination Therapy
On August 12, CMS published a Proposed Decision Memo regarding changes to two NCDs which are separate yet medically related. CMS is proposing to eliminate NCD 20.9 for Artificial Hearts and Related Devices and to revise NCD 20.9.1 providing coverage for VADs for bridge-to-transplant and destination therapy. The revisions to NCD 20.9.1 would allow for coverage for left VADs (LVAD) if FDA-approved for short-term (bridge-to-recovery/bridge-to-transplant) or long-term (destination therapy) mechanical circulatory support for heart failure patients who meet certain conditions.
CMS published a Press Release on the proposed decision memo on the same date. By posting the decision memo, CMS initiates a 30-day public comment period on the changes. Comments are due by September 11.
Quarterly Listing of Program Issuances--April through June 2020
On August 12, CMS published a Notice in the Federal Register regarding the quarterly posting of all CMS manual instructions, substantive and interpretive regulations, and other Federal Register notices published from April through June 2020.
Comment Request: Hospice Quality Reporting Program
On August 13, CMS published a Comment Request in the Federal Register regarding an information collection titled “Hospice Quality Reporting Program.” Comments are due by October 13, 2020.
Comment Request: Annual MLR and Rebate Calculation Report and MLR Rebate Notices; Conditions for Coverage of Suppliers of End Stage Renal Disease (ESRD) Services and Supporting Regulations; more
On August 14, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:
- Annual MLR and Rebate Calculation Report and MLR Rebate Notices
- Data Collection for Medicare Facilities Performing Carotid Artery Stenting with Embolic Protection in Patients at High Risk for Carotid Endarterectomy
- Conditions for Coverage of Suppliers of End Stage Renal Disease (ESRD) Services and Supporting Regulations
- Clinical Laboratory Improvement Amendments (CLIA) Regulations
Comments are due to the OMB desk officer by September 14, 2020.
Medicare Laboratory Test Expenditures Increased in 2018 Despite New Rate Reductions
On August 14, the OIG published a Review of Medicare Part B spending for laboratory tests under the clinical lab fee schedule (CLFS) in 2018. The OIG found that total Medicare spending for clinical lab tests increased by $459 million from 2017 to 2018. Payment rates for 75% of tests decreased in 2018, but overall spending increased because of increased spending on genetic tests, the end of a discount on certain chemistry tests, and the move to a single national fee schedule. The OIG stated that continued oversight of genetic testing will be important, as even a small number of inappropriate tests could lead to extremely high spending. It also recommended that CMS seek legislative authority to establish a mechanism to control costs for automated chemistry tests.
Trump Administration Has Issued More Than $15 Million in Fines to Nursing Homes During COVID-19 Pandemic
On August 14, CMS published a Press Release to announce it has imposed more than $15 million in civil money penalties across more than 3,400 nursing homes nationwide during the PHE for noncompliance with infection control requirements and failure to report COVID-19 data. CMS has completed infection control surveys in over 99.2% of nursing homes and found more than 180 immediate jeopardy-level findings, triple the rate of the deficiencies found in 2019. It also cited more than 3,300 deficiencies in nursing homes reporting COVID-19 data.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020
On August 14, CMS published Medicare Claims Processing Transmittal 10305, which rescinds and replaces Transmittal 10215, dated July 10, 2020, to update the codes in the spreadsheet for NCD 190.15. The original transmittal was issued regarding changes in the laboratory NCD code lists for October 2020.
CMS published MLN Matters 11889 on the same date to accompany the transmittal.
Effective date: October 1, 2020
Implementation date: October 5, 2020