This week in Medicare updates—10/21/2020

Medicare Updates Data on COVID-19 Impacts on Medicare Beneficiaries

On October 9, CMS updated a Data Snapshot regarding Medicare beneficiaries and COVID-19. The data provides information on Medicare beneficiaries based on encounters from January 1 to August 15. Claims used to provide this data had to have been received by September 11. Some of the findings from this most recent release include:

• There are now over 1 million total COVID-19 cases among Medicare beneficiaries and nearly 285,000 hospitalizations. The previous month’s data release indicated there were nearly 775,000 total COVID-19 cases among Medicare beneficiaries with 214,000 total COVID-19 hospitalizations.
• The average Medicare payment per fee-for-service Medicare COVID-19 hospitalization was $24,582, a slight decrease from the previous month’s average of $25,024. Medicare fee-for-service payments totaled $4.4 billion for COVID-19 hospitalizations by August 15, up from $3.5 billion the previous month. 
• Dual-eligible beneficiaries continue to be hospitalized at significantly higher rates than beneficiaries with Medicare only. The top four chronic conditions prevalent among fee-for-service beneficiaries hospitalized due to COVID-19 include hypertension (80%), hyperlipidemia (62%), chronic kidney disease (52%), and diabetes (51%).
• According to discharge data, 22% of Medicare patients hospitalized with COVID-19 died.

 

CMS Takes Action to Protect Integrity of COVID-19 Testing

On October 9, CMS published a Press Release to announce it is cracking down on labs testing for COVID-19 without an up-to-date CLIA certification. Since August 12, CMS issued 171 cease and desist letters to facilities who did not have proper CLIA certifications in place. Approximately ⅔ of those letters went to labs performing COVID-19 testing outside the scope of their existing CLIA certification, and ⅓ of the letters went to facilities conducting lab testing without a CLIA certificate. Every facility conducting COVID-19 testing is considered a lab and must be certified under CLIA. 

 

Correction Notice: CY 2021 Policy and Technical Changes to the Medicare Advantage Program, Prescription Drug Benefit Program, and Cost Plan Program

On October 13, CMS published a Correction Notice in the Federal Register regarding corrections to the CY 2021 Medicare Advantage and Part D Final Rule, dated June 2, 2020. This notice corrects several technical errors from the final rule, including errors pertaining to information collections, an incorrect disclaimer that was not applicable to the published final rule, and errors with identification numbers. 

Effective date: This correcting document is effective October 13, 2020.

 

Medicare Improperly Paid Physicians For More Than Five Spinal Facet-Joint Injection Sessions During a Rolling 12-Month Period

On October 13, the OIG published a Review of whether Medicare paid physicians for selected facet-joint injection sessions in accordance with federal requirements. Coverage of facet-joint injections is limited to no more than five injections during a rolling 12-month period for 11 of the 12 MACs. However, the OIG found that Medicare made improper payments in all 11 of those MACs for facet-joint injections in excess of that five injection limitation. These improper payments totaled $748,555, and the OIG determined that if the one MAC without the coverage limitation had limited injections to five per 12-month period, Medicare could have saved $513,328. The OIG determined that CMS’ oversight was not adequate to prevent or detect these payments. The OIG recommends the MACs recover the $748,555 in improper payments, recover any improper payments for this service after the audit period, and notify appropriate physicians so they can return any similar overpayments. It also recommends CMS develop oversight mechanisms for MACs to prevent or detect payments for more than five facet-joint injections in a 12-month period and work with the one MAC who does not have this coverage limitation to determine whether the five injection limit should be re-implemented. CMS concurred with the recommendations.

 

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2021

On October 13, CMS published Medicare Financial Management Transmittal 10394 regarding notification of the new interest rate for Medicare overpayments and underpayments. The Department of the Treasury has changed the private consumer rate to 9.375%. 

Effective date: October 20, 2020

Implementation date: October 20, 2020

 

CMS Expands List of Telehealth Services Paid Under FFS Medicare During COVID-19 PHE

On October 14, CMS published a Press Release announcing it is expanding the list of telehealth services which fee-for-service Medicare will pay for during the COVID-19 PHE. There are 11 new services that will be added to the list. These include certain neurostimulator analysis and programming services as well as cardiac and pulmonary rehabilitation services. The full list of telehealth services is available for download here.

 

Trump Administration Announces Beginning of Open Enrollment

On October 15, CMS published a Press Release to announce that 2021 Medicare Open Enrollment is officially open and will run through December 7, 2020. As part of the announcement, CMS also reminded beneficiaries to get their flu shot, beware of open enrollment scams, and seek virtual assistance if they need help enrolling in a plan.

 

CMS Changes Medicare Payment to Support Faster COVID-19 Diagnostic Testing

On October 15, CMS published a Press Release regarding new actions CMS is taking to incentivize labs to expedite the COVID-19 testing process. Effective January 1, 2021, CMS will change the base rate for payments for COVID-19 tests run on high throughput technology to $75. However, CMS will make an add-on payment of $25 per test ($100 per test total) to labs who complete high-throughput COVID-19 diagnostic tests within two calendar days of specimen collection and who complete the majority of their COVID-19 diagnostic tests in two days or less for all of their patients (not just Medicare patients). Labs should use HCPCS code U0005 to code for the add-on payment. 

 

Updated OIG Work Plan

On October 15, the OIG updated its Work Plan with the following new items:

• Comparison of Average Sales Prices and Average Manufacturer Prices
• Mandatory Review of HHS Agencies' Annual Accounting of National Drug Control Program Funds
• Nationwide Review of the Administration and Oversight of Physician-Administered Drugs
• Ineligible Providers in Medicare Part C and Part D

 

New Waived Tests

On October 15, CMS published Medicare Claims Processing Transmittal 10397, which rescinds and replaces Transmittal 10381, dated October 2, 2020, to revise the date in the background section for 87804QW. 

On October 15, CMS revised MLN Matters 11982 to accompany the transmittal. 

Effective date: January 1, 2021

Implementation date: January 4, 2021

 

CMS Survey Data Illustrates Impact of COVID-19 on Medicare Beneficiaries’ Daily Life and Experiences

On October 16, CMS published Survey Data from the Medicare Current Beneficiary Survey COVID-19 Summer 2020 supplement, which was conducted from June 10 through July 15. One of the topics addressed in the survey was whether beneficiaries did not receive healthcare due to the pandemic. The survey showed that 21% of beneficiaries reported that they needed care for something other than COVID-19 but did not receive it. The top types of missed care included dental care (43%), regular check-ups (36%), treatment for ongoing conditions (36%), and diagnostic or medical screening test (32%). When beneficiaries decided to forgo care, the top reason for doing so was not wanting to risk being at a medical facility (45%). For healthcare providers who rescheduled care, the top reason for doing so was because their office was closed (38%). The survey also looked at access to telemedicine, and 60% of beneficiaries reported that their usual health care provider currently offers telephone or video appointments. In terms of access to technology, 82% of beneficiaries indicated they had access to the internet. 

CMS published a Press Release to accompany the survey data release. It also published a Download Link to the full survey dataset. 

 

Cedars-Sinai Medical Center: Audit of Medicare Payments for Bariatric Surgeries

On October 16, the OIG published a Review of whether Cedars-Sinai Medical Center complied with Medicare requirements and relevant LCDs/LCAs when billing for bariatric surgeries. The OIG found that Cedars-Sinai did not comply with requirements for 25 of the 62 claims reviewed, as it did not provide adequate documentation of beneficiaries’ multidisciplinary medical evaluations or participation in weight management. There were also 12 claims for which Cedars-Sinai did not comply with LCDs (totaling $154,074 in improper payments) and 13 claims for which Cedars-Sinai did not comply with LCAs (totaling $175,199 in improper payments). The OIG recommends Cedars-Sinai refund Medicare for the bariatric surgery claims that did not comply with LCD specifications, return any similar payments in accordance with the 60-day rule, work with Noridian to take any necessary action for the claims which did not comply with LCAs, update its patient checklist to include all Noridian specifications for billing bariatric surgeries, and obtain supporting medical record documentation from other providers before performing any future bariatric surgeries. Although Cedars-Sinai challenged some of the OIG’s findings, the OIG maintained that its findings and recommendations are correct. 

 

Correction: Alternative Payment Model (APM) Incentive Payment Advisory for Clinicians--Request for Current Billing Information for Qualifying APM Participants

On October 16, CMS published a Correction in the Federal Register regarding a payment advisory published on September 17. CMS included an incorrect phone number in that notice and is using this notice to correct the contact information. The original advisory was issued to alert clinicians who are qualifying APM participants and eligible to receive APM incentive payments that CMS doesn’t currently have the billing information necessary to disburse payment. 

Dates: This correction is effective October 14, 2020.

 

Enforcement Discretion Relating to Certain Pharmacy Billing

On October 16, CMS published a Special Edition MLN Connects to announce it will exercise enforcement discretion in order to allow Medicare-enrolled immunizers, including but not limited to pharmacies, to bill directly and receive direct reimbursement from Medicare for vaccinating Medicare SNF residents. This will be effective until the end of the calendar year in which the PHE ends or for as long as CMS determines that there is a need for mass COVID-19 vaccinations in these settings.   

 

Application from DNV-GL Healthcare USA, Inc. for Continued Approval of its Critical Access Hospital Accreditation Program

On October 16, CMS published a Final Notice in the Federal Register to announce it has approved DNV-GL Healthcare USA, Inc. for continued recognition as a national accrediting organization for critical access hospitals that wish to participate in Medicare or Medicaid.

Dates: The approval announced in this final notice is effective December 23, 2020 through December 23, 2024.

 

Town Hall Meeting on the FY 2022 Applications for New Medical Services and Technologies Add-On Payments

On October 16, CMS published a Notice of Meeting in the Federal Register to announce the dates for the next Town Hall meeting discussing FY 2022 applications for add-on payments for new medical services and technologies under the IPPS. The meeting will be held virtually on December 15 and 16 and will begin at 9 a.m. ET each day. More details and registration information is included in the notice.

 

Ambulance Inflation Factor (AIF) for CY 2021 and Productivity Adjustment

On October 16, CMS published Medicare Claims Processing Transmittal 10396 regarding the addition of the 2021 AIF into the manual so the contractors can accurately determine payment amounts for ambulance services. The AIF for 2021 is 0.2%.

CMS published MLN Matters 12031 on the same date to accompany the transmittal. 

Effective date: January 1, 2021

Implementation date: January 4, 2021