This week in Medicare updates—7/26/2023
Proposed Decision Memo: Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease
On July 17, CMS published a Proposed Decision Memo regarding NCD 220.6.20. CMS is proposing to end coverage with evidence development (CED) for PET beta amyloid imaging and leaving coverage decisions for this technology up to the MACs. CMS initially opened reconsideration of this NCD because it is anticipated that clinical study protocols may involve more than one scan per patient.
Comments are due by August 16.
Ligature Risk and Assessment in Hospitals
On July 17, CMS published a Memorandum to state survey agency directors regarding requirements for hospitals under the Conditions of Participation at §482.13(c)(2) to provide care in a safe setting. The memo focuses specifically on ligature risk, and it reviews three elements (patient assessment, staffing/monitoring, environmental risk) hospitals should consider in managing ligature risk and assessment.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.
New Domestic N95 Respirator Payment Adjustments
On July 17, CMS published an MLN Fact Sheet regarding new payment adjustments to hospitals for their share of the additional costs for domestic N95 respirators. The fact sheet discusses who can request the payment adjustments, what supporting documentation is necessary, how to request the payment adjustments, and more.
Updated OIG Work Plan
On July 17, the OIG updated its Work Plan with the following new items:
- Medicare Part C High-Risk Diagnosis Codes Tool Kit
- Audit of Nursing Homes' Emergency Power Systems
- Audit of Ambulance Services Supplemental Payment Program
- CMS Oversight of States' Preparation of the CMS-64 Report
- CMS May Make Increased Payments to MA Organizations for Diagnoses That Were Reported on Physicians' Claims But Were Not Confirmed on a Concurrent Inpatient Stay
- Medicare Advantage Payments Generated by Health Risk Assessments for 2022
Request for Information: Episode-Based Payment Model
On July 18, CMS published a Request for Information in the Federal Register to request comments on the design of a future episode-based payment model. CMS is looking to design a new episode-based payment model focused on accountability for quality and cost, health equity, and specialty integration. It is not looking for feedback on models which address particular conditions but instead would like comments about a broader set of questions related to care delivery and incentive structure alignment.
Comments are due by August 17.
High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns about Access to Care in Medicaid Managed Care
On July 19, the OIG published a Report regarding prior authorization denials in Medicaid managed care organizations (MCO). The OIG conducted a review because of allegations that MCOs may have inappropriately delayed or denied care for thousands of people and because of a Congressional request to evaluate whether MCOs are providing medically necessary health care to their enrollees. The OIG found that one out of every eight prior authorization requests included in the review was denied, and of the 115 MCOs included in the review, 12 had prior authorization denial rates over 25%, which is double the overall rate.
The OIG is concerned because it said state Medicaid agencies did not conduct robust oversight of MCO decisions on prior authorization requests, and many state Medicaid agencies said they do not have a mechanism for patients and providers to submit a prior authorization denial to an external medical reviewer independent of the MCO. The OIG said Medicaid enrollees only appealed a small number of these denials.
The OIG recommends CMS require states to review the appropriateness of a sample of MCO prior authorization denials regularly, require states to collect data on MCO prior authorization decisions, issue guidance to states on the use of MCO prior authorization data for oversight, require states to implement medical reviews of upheld MCO prior authorization denials, and work with states to identify and address MCOs who may be issuing inappropriate prior authorization denials.
Inpatient Admission Before Part A Entitlement: Bill Correctly
On July 20, CMS published a Note in MLN Connects to provide pre-entitlement billing instructions for inpatient admissions. While the information is from the Medicare manuals, CMS’ inclusion of this information in MLN Connects indicates CMS is either seeing frequent issues with this type of billing or will be focusing on this type of billing. The note includes background on how CMS calculates payment and provides billing and claims tips.
2022 Hospice Aggregate Cap Calculation
On July 20, CMS published One-Time Notification Transmittal 12129 regarding instructions to the MACs on how to calculate the 2022 hospice aggregate cap determination given the various sequestration percentages applicable to the 2022 hospice year.
Effective date: August 21, 2023
Implementation date: August 21, 2023
Revision to State Operations Manual (SOM) Appendix A - Hospitals
On July 21, CMS published State Operations Provider Certifications Transmittal 216 regarding updates to the interpretive guidance for §482.13(c)(2) about patient rights to care in a safe setting. There are minor changes to the language in red, as well as a reference to the 2018 report from the National Action Alliance for Suicide Prevention, which CMS says hospitals can use as a resource to better provide care for people with suicide risk.
Effective date: July 21, 2023
Implementation date: July 21, 2023
Patient-Driven Payment Model (PDPM) Corrections to Claims Processing Edits
On July 21, CMS published One-Time Notification Transmittal 12146 regarding updates to claims processing edits for SNFs when there is an interrupted stay. The changes apply to SNFs billing on TOB 21X and hospitals billing on swing bed TOB 18X.
CMS published MLN Matters 13240 on the same date to accompany the transmittal.
Effective date: October 1, 2019
Implementation date: January 4, 2024
Instructions to Process Services During Disenrollment from the Programs of All-Inclusive Care for the Elderly (PACE)
On July 21, CMS published Medicare Claims Processing Transmittal 12148 regarding system changes for when a PACE patient has an inpatient stay that cannot be split during disenrollment from PACE. When a PACE patient is inpatient and disenrolls from PACE during a stay, providers should use condition code 35 and value code 42 to prevent claims denials.
CMS published MLN Matters 13248 on the same date to accompany the transmittal.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Medicare Claims Processing Manual Update to Remove Certain Transplant References
On July 21, CMS published Medicare Claims Processing Transmittal 12130 to remove references in Chapter 3 of the manual to contractors determining if the facility is certified for adults and/or pediatric kidney transplants, heart transplants, and intestinal - multi-visceral transplants, dependent on the patient’s age.
Effective date: August 21, 2023
Implementation date: August 21, 2023
Updates of Chapters 4, 8, and Exhibits in Medicare Program Integrity Manual, Including Adding Clarification to Ongoing Direction
On July 21, CMS published Medicare Program Integrity Transmittal 12127 regarding updates to the manual to remove the directive that UPICs shall not employ temporary employees, add clarification for handling potential assignment violations/Congressional inquiries/HPMS memos, and revise sections referencing program integrity contractor coordination with business function leads and contracting officer’s representatives. CMS also updated the definition in the exhibits section for a UPIC case.
Effective date: August 21, 2023
Implementation date: August 21, 2023