This week in Medicare updates—9/14/2022
Reducing Medicare’s Payment Rates for Intermittent Urinary Catheters Can Save the Program and Beneficiaries Millions of Dollars Each Year
On September 6, the OIG published a Report regarding Medicare’s payments for intermittent urinary catheters and the methods available to reduce payment rates for these catheters. The OIG found that Medicare is paying way more for intermittent catheters ($407 million) than suppliers are paying to acquire these catheters ($121 million). The OIG said there is a potential for savings across all categories of catheters, and while it acknowledged that suppliers face other costs aside from simply acquisition costs, it said the difference in the acquisition costs and the Medicare payments is far too vast.
The OIG recommends Medicare lower payment rates for intermittent urinary catheters and noted that CMS has previously protected beneficiary access by using competitive bidding or an inherent reasonableness process when seeking to obtain savings for other items. CMS said it would take the OIG’s recommendation under consideration as it determines next steps.
Approval of Application from the Det Norske Veritas for Continued Hospital Accreditation Program
On September 6, CMS published a Notice in the Federal Register to announce that it has approved the application from Det Norske Veritas for continued recognition as a national accrediting organization for hospitals that wish to participate in Medicare or Medicaid.
Dates: The decision announced in this final notice is effective through September 26, 2026.
Make Your Voice Heard Request for Information
On September 6, CMS published a Press Release regarding a Request for Information (RFI) CMS is issuing in an attempt to gain feedback on health equity, access, and the impact of waivers and flexibilities provided in response to the COVID-19 PHE. The RFI aligns with the Biden Administration’s overall efforts to advance health equity–especially among racial and ethnic minorities and underserved communities. CMS is also using this RFI to better understand the factors impacting provider wellness and to learn more about the impact of CMS policies, documentation and reporting requirements, operations, and communications on provider experiences.
Comments on the RFI are due by November 4.
Certain Medicare Beneficiaries Were More Likely Than Others to Use Telehealth During the First Year of the COVID-19 Pandemic
On September 7, the OIG published a Data Brief regarding telehealth use during the COVID-19 pandemic. The data brief is part of a series of OIG analyses examining the use of telehealth in Medicare and potential program integrity concerns related to telehealth during the pandemic. This data brief examines the types of beneficiaries who were more likely to use telehealth. The OIG found beneficiaries in urban areas were more likely to use telehealth, as were dually eligible, Hispanic, younger, and female beneficiaries. Telehealth use was also most common in Massachusetts, Delaware, and California. It found beneficiaries almost always used telehealth from home or other non-healthcare settings.
The OIG recommends that as CMS, HHS, and Congress consider permanent changes to Medicare telehealth services, they should balance concerns about access, quality of care, cost, health equity, and program integrity. It also recommends CMS take steps to enable a successful transition from current pandemic-related flexibilities to long-term policies for the use of telehealth in urban areas and from the beneficiary’s home. In addition, the OIG recommends CMS temporarily extend the use of audio-only telehealth services and evaluate their impact, require a modifier to identify all audio-only telehealth services provided in Medicare, and use telehealth to advance health care equity.
Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
On September 7, the OIG published a Data Brief as part of a series of OIG analyses examining the use of telehealth in Medicare and potential program integrity concerns related to telehealth during the pandemic. This data brief examines provider billing for telehealth services and identifies ways to safeguard Medicare from fraud, waste, and abuse. For the data brief, the OIG focused its analysis on 742,000 providers who billed for telehealth services between March 1, 2020 - February 28, 2021. The OIG developed seven measures to identify high-risk telehealth billing (such as billing for both telehealth and a facility fee for a majority of visits, billing for both fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services, etc.) and set high thresholds for those measures in an aim to identify providers whose billing poses a high risk to Medicare. The OIG noted that the specificity of this analysis does not capture all concerning billing related to telehealth in Medicare and said incident-to billing is hard for them to monitor in these types of reviews but can also pose a program integrity risk.
Overall, the OIG identified 1,714 providers whose telehealth billing seems to pose a high risk to Medicare. These providers received a total of $127.7 million in Medicare fee-for-service payments. The OIG said more than half of the high-risk providers are part of a medical practice where at least one other provider’s billing also seemed to pose a high risk to Medicare, suggesting that certain practices are encouraging a certain type of billing among their providers. The OIG recommends CMS strengthen monitoring and targeted oversight of telehealth services, provide additional education to providers on appropriate billing for telehealth services, improve transparency of incident-to services when clinical staff primarily delivered the telehealth service, identify telehealth companies that bill Medicare, and follow up on providers identified in the report. CMS concurred with recommendations to follow up with providers identified in the report but did not indicate whether it concurred with any other recommendations.
Comment Request: Advance Beneficiary Notice of Noncoverage (ABN); more
On September 7, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Annual Notice of Chance and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials
- Advance Beneficiary Notice of Noncoverage (ABN)
- Medical Necessity and Contract Amendments Under Mental Health Parity
Comments are due by November 7.
Comment Request: Medicare Self-Referral Disclosure Protocol
On September 7, CMS published a Comment Request in the Federal Register regarding the submission of the following information collection for OMB review:
- Medicare Self-Referral Disclosure Protocol
Comments are due to the OMB desk officer by October 7.
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On September 8, CMS published Medicare Claims Processing Transmittal 11595, which rescinds and replaces Transmittal 11551, dated August 11, to add a note to the policy section for HCPCS code 0340U saying it is both a PLA and an ALDT and therefore has an indicator of N and a payment amount on the fee schedule. The original transmittal was issued regarding the quarterly update to the CLFS.
On September 8, CMS revised MLN Matters 12870 to accompany the transmittal.
Effective date: October 1, 2022
Implementation date: October 3, 2022
Billing for Hospital Part B Inpatient Services
On September 8, CMS published Medicare Claims Processing Transmittal 11589 regarding billing instructions for inpatient Part B services. Revisions affect the revenue codes that are not allowed on TOBs 012x, allowed revenue codes, and a list of services that are allowed for billing in this manner but are identified by HCPCS, not revenue codes.
Effective date: July 1, 2022
Implementation date: October 11, 2022
Revision to NCD 240.2 (Home Use of Oxygen) to Align to 1834(a)(5)(E) of the Social Security Act
On September 8, CMS published National Coverage Determinations Transmittal 11587 regarding a revision to NCD 240.2 in the manual which changes the initial coverage period from 120 days to 90 days to align with statute. This policy change was finalized on July 8, 2022 and is now being added to the manual.
Effective date: September 27, 2021
Implementation date: January 3, 2023
October 2022 Integrated Outpatient Code Editor (I/OCE) Specifications Version 23.3
On September 9, CMS published Medicare Claims Processing Transmittal 11593 regarding the October update to the I/OCE.
Effective date: October 1, 2022
Implementation date: October 3, 2022
October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On September 9, CMS published Medicare Claims Processing Transmittal 11594 regarding the October update to the OPPS. Changes include new COVID-19 CPT Vaccines and Administration codes, status indicator revisions for bone density studies, skin substitute coding changes, and more.
Effective date: October 1, 2022
Implementation date: October 3, 2022