This week in Medicare updates—8/23/2023
Updated Federally Qualified Health Center (FQHC) Booklet
On August 14, CMS updated an MLN Booklet geared toward FQHCs to add information about chronic pain management services, COVID-19 monoclonal antibody payment information, cost report information, telehealth definitions, and more.
Updated OIG Work Plan
On August 15, the OIG updated its Work Plan with the following new items:
- Maintaining Buprenorphine Treatment for Medicare Enrollees With Opioid Use Disorder
- Medicare Part B Payments for Over-the-Counter COVID-19 Tests During the PHE Demonstration
Tenth General Update to Provider Enrollment Instructions in Chapter 10 of Medicare Program Integrity Manual
On August 17, CMS published Medicare Program Integrity Transmittal 12209 regarding several updates to Chapter 10 of the manual. The changes affect information about revocation reasons for a re-enrollment bar, DMEPOS form processing directions, rural emergency hospital eligibility determinations, address changes on model letters, and more.
Effective date: September 17, 2023
Implementation date: September 17, 2023
Influenza Vaccine Payment Allowances - Annual Update for 2023-2024 Season
On August 17, CMS published Medicare Claims Processing Transmittal 12211 regarding the annual update to payment allowances for the influenza vaccine. Part B payment for the vaccine is based on 95% of the average wholesale price (AWP) except when furnished in hospital outpatient departments, rural health clinics, or federally qualified health centers, where payment is based on reasonable cost.
Effective date: August 1, 2023
Implementation date: October 2, 2023 - No later than September 30, 2023; November 1, 2023 - Business Requirement 3.1
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On August 17, CMS published Medicare Claims Processing Transmittal 12210 regarding the quarterly update to the CLFS. Changes affect specimen collection fees, proprietary laboratory analysis (PLA) codes, and more.
CMS published MLN Matters 13321 on the same date to accompany the transmittal.
Effective date: October 1, 2023
Implementation date: October 2, 2023
COVID-19 Vaccine CPT Code Updates
On August 17, CMS updated its Vaccine Pricing webpage to note that Medicare will no longer pay for a variety of codes for certain Janssen, Moderna, and Pfizer vaccines that are no longer authorized by the FDA. Those codes and the end dates for their effective period are listed in a table on the webpage.
Medicare Made $17.8 Million in Potentially Improper Payments for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTP)
On August 18, the OIG published a Review of whether payments made to OTPs for OUD treatment services complied with Medicare requirements. The OIG determined that, of the $364.1 million in Medicare payments included in the sample, Medicare made up to $17.8 million in potentially improper payments. More than half of these improper payments pertained to claims for which a bundled payment was made for a weekly episode of care that was covered by a payment for another weekly bundle for the same enrollee at the same OTP. The OIG noted that in certain instances, a beneficiary may have received treatment on two separate dates of service within the seven-day contiguous period covered by the weekly bundle but the types of services were reported by different codes, and Medicare paid for both codes when it should have only paid for one. A similar situation occurred where beneficiaries may have received different drug treatments on the same date of service, the treatments were reported under two different codes, and Medicare paid both instead of only paying one.
The OIG also noted improper payments for take-home supplies of medication covered by other payments for take-home supplies or by payments for weekly bundles, improper payments for OUD services without an OUD diagnosis, and improper payments for intake activities that occurred a total of 14 or more times for the same enrollee. The OIG said improper payments occurred in part because CMS did not instruct MACs to implement system edits to prevent OTPs from being paid for OUD treatment services covered by other Medicare payments for the same enrollee at the same OTP.
The OIG made six recommendations to CMS, including recommendations to instruct MACs to implement edits to prevent double-paying weekly bundles, to revise billing guidance regarding add-on HCPCS codes for take-home supplies of medication, to develop billing requirements for OTPs to include OUD diagnoses codes on claims for OUD treatment services, and more. CMS concurred with four of the six recommendations. It did not state whether it concurred with the recommendation regarding diagnosis codes, but said it continues to explore ways to educate providers about including an OUD diagnosis code on claims.
OIG Advisory Opinion No. 23-05
On August 18, the OIG published an Advisory Opinion regarding a proposed arrangement involving a company that provides intraoperative neuromonitoring (IONM) services and a group of physicians who perform surgeries during which IONM services are used. The requestor (the IONM provider) would create and operate a turnkey entity that would perform the IONM services and would be owned by the physicians performing the surgeries. The IONM provider certified that it would be entering into this proposed arrangement to seek a competitive advantage over other IONM companies. The requestor was seeking an opinion as to whether this arrangement would constitute grounds for the imposition of sanctions under the exclusion authority or civil monetary penalty provisions related to the anti-kickback statute.
The OIG said this arrangement would constitute grounds for sanctions under the anti-kickback statute, and multiple streams of remuneration could induce the physician group to make referrals for IONM services for which payment could be made by a federal healthcare program. It noted that this arrangement would raise concerns about patient steering, unfair competition, inappropriate utilization, and increased costs to federal healthcare programs, and it exhibits many attributes of problematic contractual joint ventures about which the OIG has longstanding concerns.
Hawaiian Wildfire Emergency Waivers
On August 18, CMS published multiple resources on its Current Emergencies webpage regarding special flexibilities for those affected by the August Hawaiian wildfires. A public health emergency was declared in Hawaii on August 11 and is effective retrospective to August 8. Amongst the resources, CMS published a Fact Sheet about waivers and flexibilities which extends beyond the standard natural disaster emergency provisions for enrollment and dialysis access waivers to also include waivers and flexibilities to expand access to telehealth, allow off-site emergency screening for hospitals/psychiatric hospitals/CAHs, provide flexibilities about patient housing, and more.
CMS published a News Alert about wildfire relief on August 12.