This week in Medicare—9/20/2023
Medicare Improperly Paid Acute Care Hospitals for Inpatient Claims Subject to the Post-Acute Care Transfer Policy But CMS System Edits Were Effective in Reducing Improper Payments
On September 12, the OIG published a Review of whether Medicare paid acute care hospital inpatient claims properly when subject to the post-acute care transfer policy. The OIG looked at claims with dates of service from January 1, 2019 through December 31, 2022. It identified inpatient claims with patient status codes indicating a discharge to home or certain types of health care institutions, then narrowed those down to claims where services furnished in a post-acute care setting began on the same day as the inpatient discharge (for SNFs) or within three days of the inpatient discharge (for home health). This led the OIG to examine 12,133 inpatient claims subject to the transfer policy that were improperly billed by hospitals, as none of these claims should have been reimbursed for the full MS-DRG payment. Approximately 2/3 of the claims in error were for SNF transfers, and 1/5 were for hospice transfers. In total, Medicare improperly paid $41.4 million during the audit period to acute care hospitals for inpatient claims subject to the transfer policy.
While CMS made improper payments for these claims during the course of the audit period, the amount of improper payments varied throughout. At the beginning of the audit period, CMS’ pre and postpayment edits in the CWF were generally effective at detecting these claims, but issues within the CWF system prevented those edits from working properly and improper payments increased during October and November 2019. When CMS fixed that issue, improper payments decreased until October 2020, when an update to the claims processing system prevented the postpayment edit from working properly. CMS did not fix the edit until April 2022, but once it did, the edits were effective again in preventing improper payments.
The OIG recommends CMS direct Medicare contractors to recover the $41.4 million in overpayments from the acute care hospitals and instruct the contractors to notify providers so they can identify, report, and return any overpayments in accordance with the 60-day rule. CMS concurred with both recommendations.
Hurricane Idalia Emergency Waivers for Georgia
On September 13, CMS published multiple resources on its Current Emergencies webpage regarding special flexibilities for those affected by Hurricane Idalia in Georgia. A public health emergency was declared in Georgia on September 12 and is effective retrospective to August 30. Waivers include special enrollment opportunities for hurricane victims, DMEPOS flexibilities, and more.
CMS published a News Alert regarding the waivers on September 14.
CMS Publishes List of Part B Drugs With Lower Coinsurance for October 1 - December 31
On September 13, CMS published a Press Release to announce the List of 34 prescription drugs for which Part B beneficiary coinsurance may be lower between October 1 – December 31, 2023. The lower coinsurance is due to the policy from the Inflation Reduction Act where people with Medicare may pay a lower coinsurance for Part B drugs if the drug’s price increases faster than the rate of inflation. The drugs on these lists may change quarterly.
Updated mRNA COVID-19 Vaccine Information
On September 14, CMS published an MLN Connects notice regarding updated codes for COVID-19 vaccines. The FDA issued an EUA for the new Moderna and Pfizer COVID-19 vaccines on September 11, and CMS is introducing six new codes for these updated vaccines (codes are effective September 11):
- 90480 - COVID-19 Vaccine Administration
- 91318 - COVID-19 Vaccine, 3 mcg/0.2 mL
- 91319 - COVID-19 Vaccine, 10 mcg
- 91320 - COVID-19 Vaccine, 30 mcg
- 91321 - COVID-19 Vaccine, 25 mcg
- 91322 - COVID-19 Vaccine, 50 mcg
CMS also listed the codes for the bivalent COVID-19 vaccines that are no longer authorized for use in the United States, effective September 12. CMS published a Download Link for the file of 2023 geographically-adjusted payment rates for COVID-19 vaccine administration in accordance with these changes on its Vaccine Pricing webpage.
CMS included a Fact Sheet from March 2023 to accompany the Press Release as a reminder of how this policy works.
Quarterly Update to the NCCI Procedure-to-Procedure (PTP) Edits, Version 30.0, Effective January 1, 2024
On September 15, CMS published Medicare Claims Processing Transmittal 12246 regarding the regular quarterly updates to the NCCI PTP edits. The file should be available on or around November 17.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Revision to Implementation of Consolidated Appropriations Act (CAA) of 2023, Section 4143: Waiver of Cap on Annual Payments for Nursing and Allied Health Education Payments
On September 15, CMS published One-Time Notification Transmittal 12251 regarding the implementation of a policy finalized in the FY 2024 IPPS Final Rule that waives a cap on annual payments for nursing and allied health education. Because of this policy, MACs may need to recalculate certain nursing and allied health education Medicare Advantage payments. The transmittal walks through how MACs should handle this for a variety of different scenarios.
Effective date: December 29, 2022
Implementation date: March 19, 2024
Modernize the Vaccine Process and Roster Billing – Full Agile Pilot CR
On September 15, CMS published One-Time Notification Transmittal 12250 regarding the creation of an automated process to implement vaccine codes across the Medicare Shared Systems and CWF whenever new HCPCS and/or CPT vaccine codes are developed. In addition to implementing new vaccine codes more efficiently, CMS said it hopes this effort will eliminate the need for system maintainer intervention, reduce the burden of manual intervention by the MACs, and bridge the gap of how the roster billing process works across Parts A & B systems (as those processes currently use contrasting procedures).
Effective date: April 1, 2023 - FISS - Analysis of Modernizing the Vaccine Process and creation of test files; MCS - Analysis of Modernizing the Vaccine Process and Update of the ASP file input to remove the effective date requirements ; CWF - Analysis of Modernizing the Vaccine Process; July 1, 2023 - FISS - Analysis of Roster Billing; CWF - Implementing Features 1 through 5 for Modernizing the Vaccine Process; October 1, 2023 - FISS - Analysis of Roster Billing; CWF - Implementing Feature 6 for Modernizing the Vaccine Process; January 1, 2024 - FISS - Analysis, Design and Coding of Modernizing the Vaccine Process and Roster Billing; April 1, 2024 - FISS – Implementation of Modernizing the Vaccine Process and Roster Billing
Implementation date: April 3, 2023 - FISS - Analysis of Modernizing the Vaccine Process and creation of test files; MCS - Analysis of Modernizing the Vaccine Process and Update of the ASP file input to remove the effective date requirements ; CWF - Analysis of Modernizing the Vaccine Process; July 3, 2023 - FISS - Analysis of Roster Billing; CWF - Implementing Features 1 through 5 for Modernizing the Vaccine Process; October 2, 2023 - FISS - Analysis of Roster Billing; CWF - Implementing Feature 6 for Modernizing the Vaccine Process; January 2, 2024 - FISS - Analysis, Design, and Coding of Modernizing the Vaccine Process and Roster Billing; April 1, 2024 - FISS - Implementation of Modernizing the Vaccine Process and Roster Billing
Updated OIG Work Plan
On September 15, the OIG updated its Work Plan with the following new items:
- Audit of Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Bidding Program
- Audits of Medicare Part C Unlinked Chart Review Diagnosis Codes
Prior Authorization and Pre-Claim Review Program Statistics
On September 15, CMS published a Report regarding statistics from Medicare’s prior authorization and pre-claim review programs. The statistics show the number of requests received, MAC timeliness, appeals rates, and the MAC accuracy rate for the following programs:
- Prior Authorization for Certain Hospital Outpatient Department Services
- Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model
- Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items
- Review Choice Demonstration for Home Health Services (HH RCD)