This week in Medicare—10/30/2024
Medicare Part D Paid Millions for Drugs for Which Payment Was Available Under the Part A Skilled Nursing Facility Benefit
On October 22, the OIG published a Report regarding Part D payments for drugs for enrollees during Part A skilled nursing facility (SNF) stays, as payment should be made by Part A in those situations. The OIG found that for all 215 sample items, Part D improperly allowed prescription drug events (PDE) for drugs dispensed to or on behalf of Part D enrollees during their Part A SNF stays. In 89 of those cases, the SNF medical records confirmed that drugs were administered to Part D enrollees during a Part A SNF stay. For the other 136 sample items, there was no documentation to determine whether drugs from the pharmacies listed on the PDEs were administered during Part D enrollees’ Part A SNF stays. The OIG estimates that during the audit period (2018-2020), up to $465.1 million was improperly paid for drugs for which payment should have been made under the Part A SNF benefit.
The OIG recommends CMS work with plan sponsors to adjust or delete PDEs, determine the impact to the federal government related to the Part D total costs for drugs associated with the sample items, work with plan sponsors to identify similar instances of noncompliance and determine the impact to the federal government, and provide plan sponsors with timely and accurate information that would reduce instances of inappropriate Part D payment for drugs for which payment is available under the Part A SNF benefit. CMS concurred with all five recommendations.
Updates to the Conditions of Participation for Hospitals and CAHs to Report Acute Respiratory Illnesses
On October 22, CMS published a Memorandum to CMS Locations, State Agencies, Hospitals/CAHs, and other stakeholders regarding new regulatory requirements due to revised Conditions of Participation (CoP) that require all hospitals and CAHs to report information related to respiratory illnesses as finalized in the FY 2025 IPPS Final Rule. The memo discusses what information to report, how to report the information, and how the enforcement process will work. The revised CoPs are located at §§42 CFR 482.42(e) and 485.640(d).
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the CMS Location training coordinators of this memorandum.
Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions
On October 24, the OIG published a Review regarding the appropriateness of risk-adjusted payments and quality of care for enrollees when diagnoses are reported only on health risk assessments (HRA) and on no other records of services as reported in 2022 Medicare Advantage encounter data. The review also looked at the extent to which MA companies use chart reviews of information gathered as part of HRAs to add diagnoses that increase their risk-adjusted payment.
The OIG found that diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews and not on any other records in 2022 data resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. The OIG also found that just 20 MA companies (out of 157 total companies) drove 80% of that estimated $7.5 billion in payments, and those companies generated a substantially greater share of payments resulting from HRAs or HRA-linked chart reviews.
The OIG recommends CMS impose additional restrictions on the use of diagnoses reported only in in-home HRAs or chart reviews linked to in-home HRAs for risk-adjusted payments, conduct audits to validate diagnoses reported only in this manner, and determine whether select health conditions driving payments from these reviews may be more susceptible to misuse among MA companies. CMS concurred with only the third recommendation.
User Enhancement Change Request (UECR): Update the Multi-Carrier System (MCS) System Control Facility (SCF) System Element (SE) for Diagnosis Validation
On October 24, CMS published One-Time Notification Transmittal 12916 regarding the creation of a new system element that will check both the header and detail diagnosis code against each table and eliminate the need for the look-up support rule.
Effective date: April 1, 2025
Implementation date: April 7, 2025
Accountable Care Organization (ACO) Primary Care Flex Model (ACO PC Flex)
On October 24, CMS published Demonstrations Transmittal 12907 to prepare the systems to be able to process claims for the implementation of the ACO PC Flex Model. The model will be tested within the Shared Savings Program beginning January 1, 2025, and claims reductions will be effective July 1, 2025.
Effective date: April 1, 2025 – Technical Analysis, Design and Coding; July 1, 2025 – Testing and Implementation *Unless otherwise specified, the effective date is the date of service
Implementation date: April 7, 2025 – Technical Analysis, Design and Coding; July 7, 2025 – Completion of Coding, Testing and Implementation
Payments to Inpatient Rehabilitation Facilities (IRF) That Do Not Submit Required Quality Data – This CR Rescinds and Fully Replaces CR 9543
On October 24, CMS published Medicare Quality Reporting Incentive Programs Transmittal 12901 regarding updated language for the IRF 2% payment reduction process. The revisions are specific to aligning language across post-acute care settings for the CMS designated data submission system.
Effective date: June 7, 2024
Implementation date: November 26, 2024
Payments to Long-Term Care Hospitals That Do Not Submit Required Quality Data – This CR Rescinds and Fully Replaces CR 9544
On October 24, CMS published Medicare Quality Reporting Incentive Programs Transmittal 12900 regarding updated language for the LTCH 2% payment reduction process. The revisions are specific to aligning language across post-acute care settings for the CMS designated data submission system.
Effective date: June 7, 2024
Implementation date: November 26, 2024
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2025 (CR 1 of 2)
On October 24, CMS published One-Time Notification Transmittal 12903 regarding the quarterly updates to ICD-10 coding conversions and other coding updates specific to NCDs. These updates affect the following NCDs:
- NCD 30.3.3 – Acupuncture for Chronic Low Back Pain
- NCD 80.2, 80.2.1, 80.3, and 80.3.1 – Photodynamic Therapy, Ocular Photodynamic Therapy, Photosensitive Drugs, Verteporfin
- NCD 110.4 – Extracorporeal Photopheresis
- NCD 110.18 – Aprepitant for Chemotherapy-Induced Emesis
- NCD 110.21 – ESAs in Cancer and Related Neoplastic Conditions
- NCD 110.23 – Stem Cell Transplantation
- NCD 110.24 – CAR-T Cell Therapy
- NCD 190.3 – Cytogenetic Studies
Effective date: April 1, 2025 – See individual BRs for effective dates
Implementation date: November 26, 2024 – BRs 2, 7; April 7, 2025 – BRs 1, 3, 4, 5, 6, 8
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2025 (CR 2 of 2)
On October 24, CMS published One-Time Notification Transmittal 12904 regarding the quarterly updates to ICD-10 coding conversions and other coding updates specific to NCDs. These updates affect the following NCDs:
- NCD 190.11 - PT/INR for Anticoagulation Management
- NCD 200.3 – Monoclonal Antibodies
- NCD 210.3 – Colorectal Cancer
- NCD 220.6.17 – PET for Solid Tumors
- NCD 230.18 – Sacral Nerve Stimulation
- NCD 260.9 – Heart Transplants
- NCD 270.3 – Blood-Derived Products for Chronic, Non-Healing Wounds
Effective date: April 1, 2025 – See individual BRs
Implementation date: November 26, 2024 – BRs 2, 4, 5, 7; April 7, 2025 – BRs 1, 3, 6
Updating Medicare Secondary Payer Manual, Chapter 7, Section 10.8 to Include Additional Policy for Wrongful Death Claims
On October 24, CMS published Medicare Secondary Payer Transmittal 12898 regarding updates to the manual to add language and clarify policy for wrongful death claims where a settlement, judgment, award, or other payment was based entirely on the wrongful death theory of liability, as supported by appropriate documentation, and thus no medical expenses were claimed or released by the settlement procured or judgment entered, then there is no requirement that the settlement or judgment be reported, as Medicare would have no recovery rights against such a payment.
Effective date: November 26, 2024
Implementation date: November 26, 2024
Implementation of the Award for the Jurisdiction D DME MAC
On October 24, CMS published One-Time Notification Transmittal 12908 regarding the new contract for the Jurisdiction D DME MAC. CMS awarded the contract to Noridian Healthcare Solutions, the incumbent contractor for this workload.
Effective date: September 1, 2024
Implementation date: September 1, 2024
Implementation of the Award for the Jurisdiction JJ Part A and B MAC
On October 24, CMS published One-Time Notification Transmittal 12924 regarding the new contract for the Jurisdiction J A/B MAC. CMS awarded the contract to Palmetto GBA LLC, the incumbent contractor for this workload.
Effective date: September 1, 2024
Implementation date: December 8, 2024
Regional Medicare Swing-Bed Rates
On October 25, CMS published Provider Reimbursement Manual Transmittal 499 regarding the addition of Table 36 to the chapter on Determination of Cost of Services to Beneficiaries in order to update Medicare payment rates for routine SNF-type services by swing-bed hospitals during CY 2025. These rates are used to carve out swing-bed costs on the hospital cost report.
Effective date: For services furnished on or after January 1, 2025
Skilled Nursing Facility Cost Report Revisions
On October 25, CMS published Provider Reimbursement Manual Transmittal 1 regarding revisions to the SNF and SNF Complex Cost Report for FY 2025.
Effective date: Cost reporting periods beginning on or after October 1, 2024
Correcting Amendment to Final Rule: Advancing Interoperability and Improving Prior Authorization Process
On October 25, CMS published a Correcting Amendment in the Federal Register regarding a final rule on advancing interoperability and improving prior authorization that was published in the Federal Register on February 8. The correcting amendment revises paragraphs regarding beneficiary access to and exchange of data by making it clear that states must provide data in an easily accessible location and outlining what general information the states must include to protect the privacy and security of health information.
This correcting amendment is effective October 25, 2024.