Corporate Compliance

This week in Medicare updates

Medicare Insider, July 21, 2015

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Change in July 2015 update of quarterly HCPCS drug/biological code changes

On July 10, CMS rescinded Transmittal 3254, dated May 8, 2015, and replaced it with Transmittal 3292, dated July 10, 2015, to modify business requirement 9167.5 and to clarify the use of Q9977-compounded drug, not otherwise classified (NOC) HCPCS code.

Effective date: July 1, 2015
Implementation date: July 6, 2015

View Transmittal R3292CP.

Indian Health Services (IHS) Hospital Payment Rates for Calendar Year (CY) 2015

On July 10, CMS released the annual update of IHS payment rates for calendar year 2015. The attached Recurring Update Notification applies to Chapter 19, Medicare Claims Processing Manual, Section 100.3.4, 100.4.2, and 100.5.

Effective date: January 1, 2015
Implementation date: August 11, 2015

View Transmittal R3291CP.

Medical review of home health services

On July 10, CMS released a revision to Medical Review of Home Health Services to manualize policies in the CY 2015 Home Health Prospective Payment System Final Rule published on November 6, 2014. CMS finalized clarifications and revisions to policies regarding physician certification and recertification of patient eligibility for Medicare home health services.

Effective date: August 11, 2015
Implementation date: August 11, 2015

View Transmittal R602PI.

October 2015 Quarterly Average Sales Price (ASP) Medicare Part B drug pricing files and revisions to prior quarterly pricing files

On July 10, CMS released the ASP methodology based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and not otherwise classified drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor through separate instructions that can be located in Chapter 4, Medicare Claims Processing Manual, section 50 of the Internet-Only Manual. Contractors shall not search and adjust claims that have already been processed unless brought to their attention.

Effective date: October 1, 2015
Implementation date: October 5, 2015

View Transmittal R3290CP.

View MLN Matters article MM9248.

Revisions to the State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines (IG) for hospitals

On July 10, CMS released revised IGs for 42 CFR 482.26 concerning radiologic services and 42 CFR 482.53 concerning nuclear medicine provided in hospitals.

Effective date: July 10, 2015
Implementation date: July 10, 2015

View Transmittal R141SOM.

Outpatient therapy threshold claims

On July 10, CMS posted that it set restrictions on the number of Additional Documentation Requests that could be sent related to outpatient therapy threshold claims (claims over the $3,700 threshold) that were paid March 1, 2014, through December 31, 2014.

View the update.

Recovery Auditor contracts

On July 10, CMS posted that, effective June 4, 2015, it has withdrawn the Requests for Quotes for the next round of Recovery Auditor contracts. CMS plans to update the Statement of Work and release new Requests for Proposals shortly. In the meantime, the current Recovery Auditors will continue active recovery auditing through at least December 31, 2015.

View the update.

Notice of FY 2015 new interest rate for Medicare overpayments and underpayments

On July 13, CMS released a transmittal stating the private consumer rate has been changed to 9.75% which applies to charging and payment of interest on overpayments and underpayments to Medicare providers.

Effective date: July 20, 2015
Implementation date: July 20, 2015

View Transmittal R251FM.

Medicare contractor overpaid a provider that incorrectly billed for aflibercept

On July 13, the OIG posted a report stating that the Medicare contractor for Jurisdiction 1 (California, Hawaii, Nevada, American Samoa, Guam, and the Northern Mariana Islands) overpaid a provider that incorrectly billed for aflibercept by $707,000.

View the report.

Medicare Compliance Review of Saint Mary's Health Center for 2011 and 2012

On July 13, the OIG posted a Medicare Compliance Review stating Saint Mary's Health Center, operating in Saint Louis, Missouri, complied with Medicare billing requirements for 181 of the 193 inpatient and outpatient claims it reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 12 claims, resulting in overpayments of $69,000 for CYs 2011 and 2012 (10 claims) and CY 2010 (two claims).

View the report.

CMS cutting-edge technology identifies and prevents $820 million in improper Medicare payments in first three years

On July 14, CMS posted a press release stating its advanced analytics system, called the Fraud Prevention System, identified or prevented $820 million in inappropriate payments in the program’s first three years. The Fraud Prevention System uses predictive analytics to identify troublesome billing patterns and outlier claims for action, similar to systems used by credit card companies.

View the press release.

View the report.

Extension of Medicare prior authorization for Power Mobility Devices (PMD) demonstration

On July 15, CMS posted a notice in the Federal Register announcing an extension of the Medicare Prior Authorization for PMDs demonstration. This demonstration will now end on August 31, 2018.

View the notice in the Federal Register.

Reform of requirements for long-term care facilities

On July 16, CMS posted a proposed rule in the Federal Register that would revise the requirements that long-term care facilities must meet to participate in the Medicare programs. These proposed changes are necessary to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These proposals are also a part of efforts to achieve broad-based improvements both in the quality of healthcare furnished through federal programs, and in patient safety, while reducing procedural burdens on providers. Comments are due September 14.

View the proposed rule in the Federal Register.

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Home Health Compare Quality of Patient Care Star ratings

On July 16, CMS posted a fact sheet and press release explaining the Quality of Patient Care Star Rating for home health agencies on the Home Health Compare website.

View the fact sheet.

View the press release.

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