This week in Medicare updates
Updating the Shared System and CWF to no longer create veteran affairs (VA) ‘I’ record in the Medicare Secondary Payer (MSP) Auxiliary file
On June 4, CMS released a special edition MLN Matters article intended to provide additional information and coding reminders for billing Medicare when the Department of Veterans Affairs (VA) is involved for a portion of the services. This article is based on Change Request 8198 which informs MACs about clarification to procedures for institutional claims related to the VA. Make sure your billing staff is aware of these changes.
View special edition MLN Matters article SE1517.
Screening for Hepatitis C Virus (HCV) in adults–Implementation of additional CWF and Shared System Maintainer (SSM) edits
On June 19, CMS released a change request to follow-up to CR 8871, Transmittal 3215 dated March 11, 2015, entitled Screening for HCV in Adults. Change request 9200 addresses the line-item denial of HCV claims for those born outside the years 1945–1965 who do not have a high-risk indicator, as this population is not eligible for the HCV screening benefit. It also removes TOBs/payment instructions/modifies editing for rural health clinics, federally qualified health Clinics, and critical access hospitals. CMS covers screening for HCV when ordered by the beneficiary’s primary care physician or practitioner and that meets certain other conditions.
Effective date: June 2, 2014
Implementation date: For FISS shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, for non-shared MAC edits; October 5, 2015, for CWF shared systems edits
View Transmittal R3285CP.
AgeWell Physical Therapy & Wellness, P.C., claimed unallowable Medicare Part B reimbursement for outpatient therapy services
On June 19, the OIG posted a report stating AgeWell Physical Therapy & Wellness, P.C. (AgeWell), claimed Medicare reimbursement for outpatient therapy services that did not comply with Medicare requirements. On the basis of its sample results, the OIG estimated that AgeWell improperly received at least $1.4 million in Medicare reimbursement for outpatient therapy services that did not comply with certain Medicare requirements. Of the 100 claims in the random sample, AgeWell properly claimed Medicare reimbursement for 38 claims. However, AgeWell improperly claimed Medicare reimbursement for the remaining 62 claims. Of these 62 claims, 29 claims contained more than one deficiency.
View the complete report.
OIG Advisory Opinion No. 15-08
On June 19, the OIG posted an advisory opinion regarding the use of a "preferred hospital" network as part of Medicare Supplemental Health Insurance ("Medigap") policies. In this scenario, a plan would indirectly contract with hospitals for discounts on the otherwise-applicable Medicare inpatient deductibles for its policyholders and, in turn, would provide a premium credit of $100 off the next renewal premium to policyholders who use a network hospital for an inpatient stay.
Read the full opinion.
Meeting of the Advisory Panel on Outreach and Education (APOE), July 22, 2015
On June 22, CMS posted a notice in the Federal Register announcing the rescheduling of the June 25, 2015, meeting and announcing the new meeting date of the APOE in accordance with the Federal Advisory Committee Act. The meeting will now be held Wednesday, July 22, 2015, from 8:30 a.m. to 4:00 p.m. Eastern. The deadline for registration, presentations and comments is Wednesday, July 8.
View the notice in the Federal Register.
Questionable billing and geographic hotspots point to potential fraud and abuse in Medicare Part D
On June 23, the OIG posted a report stating that, since 2006, it has had ongoing concerns about drug abuse and diversion in Medicare Part D. Past OIG reviews have revealed questionable billing associated with pharmacies, prescribers, and beneficiaries. Those reviews have also raised concerns about oversight of Part D and made a variety of recommendations to better safeguard the program and protect beneficiaries.
View the report.
Ensuring the Integrity of Medicare Part D
On June 23, the OIG posted a report stating that, since Part D began, the OIG has produced a wide range of investigations, audits, evaluations, and legal guidance related to Part D program integrity. This work has resulted in the prosecution of individuals accused of defrauding Part D, as well as the identification of systemic program vulnerabilities that raise concerns related to both inappropriate payments and quality of care. OIG has made recommendations to strengthen Part D program integrity, and progress has been made. However, Part D remains vulnerable to fraud, as evidenced by ongoing investigations. OIG has prepared this portfolio to document key progress in addressing Part D program vulnerabilities and to highlight issues that need improvement.
View the report.
CMS's reliance on accreditation surveys could not ensure the quality of care provided to Medicare hospice beneficiaries by The Community Hospice, Inc.
On June 25, the OIG posted a report stating that CMS's reliance on accreditation surveys could not ensure the quality of hospice care that The Community Hospice, Inc. (Community), provided to Medicare beneficiaries. Specifically, the OIG found that Community did not meet certain federal and state requirements for criminal background checks, health assessments, professional licensing and experience, training, and performance evaluations. Of the 100 workers in the random sample, Community could not document that 51 complied with one or more of these requirements. On the basis of the sample results, the OIG estimated that 194 workers were not in compliance with federal and state requirements.
View the complete report.
Accountable Care Organization (ACO) Investment Model
On June 25, CMS posted a fact sheet about the ACO Investment Model, which is an initiative developed by the CMS’ Innovation Center for organizations participating as ACOs in the Medicare Shared Savings Program (Shared Savings Program). The ACO Investment Model is a new model of pre-paid shared savings that builds on experience with the Advance Payment Model to encourage new ACOs to form in rural and underserved areas and current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk.
View the fact sheet.