This week in Medicare updates—10/26/2022

Updated OIG Work Plan

On October 17, the OIG updated its Work Plan with the following new items:

• Potentially Preventable Hospitalizations of Medicare-Eligible Skilled Nursing Facility Residents
• Implementing Average Sales Price Reporting Requirements for Skin Substitutes

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On October 18, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including:

• On August 3, Dr. Craig Copeland, of Fayetteville, NC, agreed to a 10-year exclusion from federal health care programs to resolve allegations that he received remuneration in exchange for ordering durable medical equipment, genetic testing, and prescription medications for Medicare beneficiaries with whom he had no physician-patient relationship and had never examined.
• On August 11, Mitchell Spivack and Verree Pharmacy, of Huntington Valley, PA, and Spivack, Inc., d/b/a Verree Pharmacy, of Philadelphia, PA, agreed to a 22-year exclusion from federal healthcare programs for dispensing and distributing medically unnecessary controlled substances. 
• On August 12, Mangesh Kanvinde, MD, of Batavia, KY, agreed to a 15-year exclusion from federal healthcare programs for receiving illegal remuneration from locum tenens and telehealth companies in exchange for medically unnecessary DME and genetic testing referrals for Medicare beneficiaries with whom he had no physician-patient relationship. 
• On August 16, Danita Smith and My Blooming Health Mobile, of St. Louis, MO, agreed to a 3-year exclusion from federal healthcare programs for submitting false claims for fingersticks, travel allowances, and clotting tests.  
• On August 17, Charles Buzzanell, MD, and Blue Ridge Pain Management and Palliative Care, of Asheville, NC, reached a $286,428.70 settlement agreement with the OIG to resolve allegations that Dr. Buzzanell submitted claims to Medicare for facet joint injections and denervations in excess of the allowable amount of sessions in a rolling 12-month period. 
• On August 18, Dr. Kenneth Martinez and Neurology and Pain Specialty Center, of Aliso Viejo, CA, reached a $919,644.34 settlement agreement with the OIG to resolve allegations that Dr. Martinez submitted claims for medically unnecessary or upcoded services. 
• On August 22, Justin Thompson, DC, Arizona Pain Relief, Anthem Physical Medicine, and Biltmore Physical Medicine, of Arizona, reached a $1.9 million settlement agreement with the OIG to resolve allegations that they submitted false claims for neurostimulators. 
• On August 31, Bruce Boynton, MD, of Asheville, NC, reached a $48,790 settlement agreement with the OIG to resolve allegations that he received remuneration from two telemedicine companies in exchange for prescribing medications for Medicare beneficiaries he had never examined and with whom he had no physician-patient relationship.

The list also includes several organizations who reached settlements with the OIG to resolve allegations that they employed individuals they knew or should have known were excluded from participation in federal healthcare programs. Those organizations include:

• Key Learning Concepts
• West Bay Residential Services
• People First Supports Coordination

 

Updated Provider Self-Disclosure Settlements

On October 18, the OIG published an updated List of Provider Self-Disclosure Settlements with the following organizations:

• On September 22, University of Missouri Health Care and University Physicians, of Missouri, reached a $100,000 settlement with the OIG to resolve allegations that it provided remuneration to community physicians in the form of free continuing medical education and meals.
• On September 29, Afya Logic, of California, reached a $484,084.65 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for durable medical equipment that resulted from telehealth encounters that did not meet regulatory requirements.

The list also included several organizations who reached settlements after employing excluded individuals or submitting claims for services provided by unlicensed individuals. Those organizations include:

• Piedmont Rockdale Hospital
• Arisa Health and Mid-South Health Systems
• Hope Health and Rehabilitation Center
• Midwest Eye Consultants

 

Home Health Agencies Used Multiple Strategies to Respond to the COVID-19 Pandemic

On October 18, the OIG published a Report to provide insight into home health agencies’ (HHA) experiences during the COVID-19 pandemic to help stakeholders continue to manage the response to COVID-19 and prepare for future emergencies. The report is based on a nationwide survey that was sent out to HHAs in fall 2021 asking about their experiences during the pandemic. The OIG also interviewed a dozen HHAs about notable challenges and strategies they used to confront those challenges. HHAs noted they had long-standing staffing challenges that were further exacerbated by quarantine and isolation protocols, and they also discussed challenges with infection control processes. They identified strategies such as offering paid leave to retain staff, finding PPE from nontraditional sources, and utilizing government support via waivers and flexibilities as key tools in handling these challenges. They specifically noted that telehealth flexibilities were helpful in providing care while reducing COVID-19 exposure.

The OIG recommends CMS evaluate how HHAs are using telehealth and how the regulatory flexibilities CMS offered during the COVID-19 pandemic have affected the quality of home health care. The OIG also recommends CMS work with ASPR’s Technical Resources, Assistance Center, and Information Exchange to apply lessons learned during the pandemic and update and/or develop emergency preparedness training and materials for HHAs on responding to infectious disease outbreaks. CMS concurred with these recommendations.

 

FISS: Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Reason Code 31849

On October 20, CMS published One-Time Notification Transmittal 11649 regarding changes to SNF PDPM editing in FISS to modify reason code 31849 to reduce unnecessary claim suspension and unneeded history retrieval requests. In an attempt to reduce incorrect PDPM prior days calculations, a new reason code will be created to assign when the incoming claim should be billed as a new admission.

Effective date: April 1, 2023

Implementation date: April 3, 2023

 

Enhancements to PDPM Claim Edits to Improve Claims Processing

On October 20, CMS published One-Time Notification Transmittal 11650 regarding updates to the Medicare systems to ensure SNF PDPM claims processing edits process and pay correctly. These updates do not reflect any changes in policy–they simply align the Medicare systems with current policies.

CMS published MLN Matters 12896 on the same date to accompany the transmittal. 

Effective date: Dates of service on or after October 1, 2019

Implementation date: April 3, 2023

 

Revisions to State Operations Manual, Appendix PP Guidance to Surveyors for Long-Term Care Facilities 

On October 21, CMS published State Operations Provider Certification Transmittal 208 regarding revisions to the entirety of Appendix PP. All FTag numbers are new and much of the content of the appendix is also new. The transmittal includes over 550 pages of changes to manual instructions in red font. These apply to a variety of information, including definitions of drugs, trauma-informed care, resident rights, and more.

Effective date: October 21, 2022

Implementation date: October 24, 2022

 

Updated Corporate Integrity Agreement Documents

On October 21, the OIG published information on new Corporate Integrity Agreements with the following entities:

• CHC Holdings, LLC D/B/A Carter Healthcare, of Oklahoma City, OK
• CHC-FLA, LLC, of Oklahoma City, OK

 

Biden-Harris Administration Strengthens Oversight of Nation’s Poorest-Performing Nursing Homes

On October 21, CMS published a Press Release regarding updates to the Special Focus Facilities (SFF) program to toughen requirements for completion of the program and increase enforcement actions for facilities that fail to demonstrate improvement. These updates are part of a series of actions this administration is undertaking in an attempt to increase accountability of bad actors in the nursing home industry, improve quality, and make nursing homes safer. There are currently 88 nursing homes in the country participating in the SFF program.

CMS published a Memorandum discussing the specific changes to the program on the same date.

Effective date: Immediately. Please communicate to all appropriate staff within 30 days.

 

Updates to the CWF for Editing and Claims Processing to Allow Medicare FFS Coverage of Kidney Acquisition Costs for Medicare Advantage (MA) Beneficiaries Provided by Maryland Waiver (MW) Hospitals

On October 21, CMS published One-Time Notification Transmittal 11659, which rescinds and replaces Transmittal 11623, dated September 30, to add a note to business requirements 12589.3.1 and 12589.3.2 to clarify the implementation schedule for the new edit. The original transmittal was published regarding updates to CWF edits and claims processes to allow Medicare FFS coverage and add-on payment of kidney acquisition costs for MA beneficiaries provided by MW hospitals. 

Effective date: January 1, 2021 - Effective for claims with an admission date on or after January 1, 2021

Implementation date: July 5, 2022 - For CWF analysis, requirements, and initial coding; October 3, 2022 - For CWF coding completion, testing, and implementation

 

Extensions of Certain Temporary Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital (MDH) Program Under the Inpatient Prospective Payment System (IPPS) 

On October 21, CMS published One-Time Notification Transmittal 11660 regarding implementation of an extension for the low-volume hospital payment adjustments and MDH programs under the Continuing Appropriations and Ukraine Supplemental Appropriations Act of 2023. The low-volume hospital payment adjustments and MDH programs that were originally supposed to end on October 1, 2022 have now been extended through December 16, 2022. These changes may affect designations of MDH programs as sole community hospitals in certain circumstances, and low-volume hospitals must send written requests to their MACs by November 16 to receive the applicable low-volume percentage increase for payments for FY 2023 discharges occurring before December 17. 

CMS published MLN Matters 12970 on the same date to accompany the transmittal. 

Effective date: October 1, 2022

Implementation date: No later than November 1, 2022