On March 15, CMS increased the Medicare payment amount for administering the COVID-19 vaccine. This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. At a time when vaccine supply is growing, CMS is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

These updates to the Medicare payment rate for COVID-19 vaccine administration reflect new information about the costs involved in administering the vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare, or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

Coverage of COVID-19 Vaccines:

As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance, or deductible.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

Medicaid: State Medicaid and Children’s Health Insurance Program agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the Public Health Emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit.

Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the PHE. Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More Information:

·  Medicare COVID-19 Vaccine Shot Payment webpage: Payment for COVID-19 vaccine administration, including a list of billing codes, payment allowances, and effective dates

·  CDC COVID-19 Vaccination Program Provider Requirements and Support webpage: How the COVID-19 vaccine is provided at 100% no cost to recipients

·  HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured webpage

Final rule gives providers access to patient treatment histories, and streamlines prior authorization to improve patient experience and alleviate burden for health care providers

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.

“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”

The “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly.

Today’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking.

Prior Authorization Burden Reduction

Payers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner.

The final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically.The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems.

The final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024.In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike.

The rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly.

Today’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care.

The final rule is available to review today at: https://www.cms.gov/files/document/11521-provider-burden-promoting-patients-electronic-access-health-information-e-prior.pdf

HHS Secretary Azar has extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021.

In addition, as indicated in the summary and impact table distributed earlier this week, the Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that it is implementing the following provisions of this legislation and that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation.

Message from CMS:

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

• Provided a 3.75% increase in MPFS payments for CY 2021
• Suspended the 2% payment adjustment (sequestration) through March 31, 2021
• Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
• Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

Source: AMA

Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow, and reducing burden, this proposed rule would give providers more time to focus on their patients, and provide better quality care.

The COVID-19 pandemic has shone a harsh light on many longstanding inefficiencies in the health care system—including the lack of data sharing and access. Today’s proposed rule aims to improve this for patients navigating care. The proposed rule would build on the Trump Administration’s Interoperability and Patient Access final rule published by the CMS in May.

“This proposed rule ushers in a new era of quality and lower costs in health care as payors and providers will now have access to complete patient histories, reducing unnecessary care and allowing for more coordinated and seamless patient care. Each element of this proposed rule would play  a key role in reducing onerous administrative burden on our frontline providers while improving patient access to health information,” said CMS Administrator Seema Verma. “Prior authorization is a necessary and important tools for payors to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing adminsitrative costs for the whole system.”  Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients. If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between 1 and 5 billion dollars over the next ten years. With the pandemic placing even greater strain on our health care system, the policies in this rule are more vital than ever.”

The rule would require payers in Medicaid, CHIP and QHP programs to build application programming interfaces (APIs) to support data exchange and prior authorization. APIs allow two systems, or a payer’s system and a third-party app, to communicate and share data electronically  Payers would be required to implement and maintain these APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. The FHIR standard is an innovative technology solution that helps bridge the gaps between systems so both systems can understand and use the data they exchange.

On behalf of HHS, the Office of the National Coordinator for Health IT (ONC) is also proposing to adopt certain standards through an HHS rider on the CMS proposed rule.

Improving Prior Authorization

Prior authorization is an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply. This process takes place before a service is rendered. The rule proposes significant changes to improve the patient experience and alleviate some of the administrative burden prior authorization causes health care providers. Medicaid, CHIP and QHP payers would be required to build and implement FHIR-enabled APIs that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system. While Medicare Advantage plans are not included in today’s proposals, CMS is considering whether to do so in future rulemaking.

The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing. 

These policies, taken together, could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients. They are the result of numerous listening sessions with plans and providers aimed at crafting a new process that balances the need for greater efficiency and consistency in prior authorization and its important role in preventing fraud, abuse, and unnecessary expenditures.

Increasing Patient Access to Health Information

Building on that foundational policy, this rule would require impacted payers to implement and maintain a FHIR-based API to exchange patient data as patients move from one payer to another. In this way, patients who would otherwise not have access to their historic health information would be able to bring their information with them when they move from one payer to another, and would not lose that information simply because they changed payers. 

These proposed changes would also allow payers, providers and patients to have access to more information including pending and active prior authorization decisions, potentially allowing for fewer repeat prior authorizations, reducing burden and cost, and ensuring patients have better continuity of care. To read more on the importance of these proposed changes, please visit CMS Administrator Seema Verma’s blog post here: https://www.cms.gov/blog/reducing-provider-and-patient-burden-and-promoting-patients-electronic-access-health-information

The proposed rule is available to review today at: https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf The comment period will close on January 4, 2021.

For a copy of the Fact Sheet, visit: https://www.cms.gov/newsroom/fact-sheets/reducing-provider-and-patient-burden-improving-prior-authorization-processes-and-promoting-patients

For more information on the CMS proposed rule, please visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index

What you should know:

1. When the final rules take effect Jan. 1, 2021, CMS will begin eliminating the inpatient-only list by removing 298 primarily musculoskeletal-related services. By calendar year 2024, the full list of 1,700 procedures will be completely phased out and approved for payment in the outpatient setting when clinically appropriate.

2. The final rule includes 11 additions to the list of procedures covered in ASCs, including total hip arthroplasty (Current Procedural Terminology code 27130). The other additions made through CMS' standard review process are:

• 0266T: Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming and repositioning, when performed)
• 0268T: Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming and repositioning, when performed)
• 0404T: Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency
• 21365: Open treatment of complicated fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches
• 27412: Autologous chondrocyte implantation, knee
• 57282: Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
• 57283: Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
• 57425: Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
• C9764: Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed
• C9766: Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed

3. Under revised criteria for adding procedures to the ASC-payable list, CMS will include 267 surgical procedures in 2021. Criteria the agency used in the past should be taken into consideration by physicians deciding whether a beneficiary should be treated in an ASC. The public will be able to suggest future additions to the ASC-covered procedures list under a new notification process CMS is establishing.

4. On average across all covered procedures, ASCs will see a payment rate update of 2.4 percent. The update rate for specific codes and specialties, however, may vary significantly. 

5. CMS will not remove any existing measures or adopt new measures for the calendar year 2023 payment determination under the ASC Quality Reporting Program. Because data submission was voluntary for web-based measures during the 2019 reporting period, all ASCs that reported will receive the full ASCQRP payment update for calendar year 2021.

"CMS should be commended for recognizing that ASCs are increasingly able to safely provide a greater range of services as medical practice evolves," said Bill Prentice, CEO of the Ambulatory Surgery Center Association. "While we wish CMS had addressed our concerns about budget policies that negatively impact ASC payments, we sincerely appreciate the policies relating to allowable procedures that rely on the critical role of physicians and their clinical judgment in making site-of-service determinations."

Source: https://www.beckersasc.com/asc-news/cms-finalizes-asc-rules-for-2021-with-278-asc-payable-additions.html

Source: https://www.beckersasc.com/outpatient-spine/cms-to-require-prior-authorization-for-cervical-fusion-with-disc-removal.html

On December 1, CMS released the annual Physician Fee Schedule (PFS) final rule, prioritizing CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions. The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. This final rule takes steps to further implement President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors including prioritizing the expansion of proven alternatives like telehealth.

“During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”

“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”

Finalizing Telehealth Expansion and Improving Rural Health

Before the COVID-19 Public Health Emergency (PHE), only 15,000 Fee-for-Service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE.

This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE, and we will continue to gather more data and evaluate whether more services should be added in the future. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.

Additionally, CMS is announcing a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE. The study will explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.

Payment for Office/Outpatient Evaluation and Management (E/M) and Comparable Visits

Last year, CMS finalized a historic increase in payment rates for office/outpatient face-to-face E/M visits that goes into effect in 2021. The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary health care needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions. These payment increases, informed by recommendations from the American Medical Association (AMA), support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home.

Under this final rule, CMS continues to prioritize this investment in primary care and chronic disease management by similarly increasing the value of many services that are similar to E/M office visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. These adjustments ensure CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” Administrator Verma added. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. The changes modernize documentation and coding guidelines developed in the 1990s, and come after extensive stakeholder collaboration with the AMA and others. These changes will significantly reduce the burden of documentation for all clinicians, giving them greater discretion to choose the visit level based on either guidelines for medical decision-making (the process by which a clinician formulates a course of treatment based on a patient’s information, i.e., through performing a physical exam, reviewing history, conducting tests, etc.) or time dedicated with patients. These changes are expected to save clinicians 2.3 million hours per year in administrative burden so that clinicians can spend more time with their patients.

Professional Scope of Practice and Supervision

As part of the Patients Over Paperwork Initiative, the Trump Administration is cutting red tape so that health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. The PFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program.

Specifically, CMS is finalizing the following changes:

Certain non-physician practitioners, such as nurse practitioners and physician assistants, can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.

For More Information:

• Final Rule
• Physician Fee Schedule Final Rule fact sheet
• Quality Payment Program Final Rule fact sheet and FAQs
• Medicare Diabetes Prevention Program fact sheet

SOURCE: 
THE MEDICARE LEARNING NETWORK®, MLN CONNECTS®, AND MLN MATTERS® AREREGISTERED
TRADEMARKS OF THEU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS).
Centers for Medicare & Medicaid Services and The Medicare Learning Network

Becker's Hospital Review

CMS issued a final rule Nov. 20 that modifies the Stark Law, which prohibits physician self-referrals.  

Six things to know:

1. The agency proposed the changes to the Stark Law in October 2019, arguing that the law hasn't evolved with the transition to value-based care.

2. The final rule provides exceptions to the law for certain value-based compensation arrangements between or among physicians, other providers and suppliers. 

3. The rule has an exception for some arrangements in which a physician receives remuneration for items or services provided by the physician.

4. It also has a new exception for donations of cybersecurity technology and services and amends the existing exception for EHR items and services.

5. The modifications take effect Jan. 19.

6. The changes are the most significant alterations to the law since its 1989 inception, according to CMS. 

"The final rule unleashes innovation by permitting physicians and other healthcare providers to design and enter into value-based arrangements without fear that legitimate activities to coordinate and improve the quality of care for patients and lower costs would violate the Stark Law," CMS said in its news release.  

On Friday, U.S. Representatives Ami Bera, MD (D-Calif.), and Larry Bucshon, MD (R-Ind.), introduced bipartisan legislation to provide critical relief to physicians responding to the COVID-19 pandemic who are scheduled to receive Medicare payment cuts next year. The Holding Providers Harmless From Medicare Cuts During COVID-19 Act would ensure payments to these providers are kept stable at 2020 levels for the next two years. AAOS is working with Reps. Bera and Bucshon to increase support for the bill as one of several congressional pathways for mitigating the effects of finalized and recently proposed policies from the Centers for Medicare & Medicaid Services.

Read the press release…

View the AAOS Advocacy Action Center…

AAOS Headline News Now - November 2, 2020

Florida Medicaid Health Care Alert

October 23, 2020

Provider Type(s): 25, 26, 30

Mandatory Department of Health COVID-19 Reporting Requirements for Laboratories and Point of Care COVID-19 Testing

THIS MESSAGE APPLIES TO FACILITIES AND AGENCIES THAT HAVE A CLIA LABORATORY CERTIFICATION OR CLIA CERTIFICATE OF WAIVER OR PLAN TO APPLY

The Centers for Medicare and Medicaid Services (CMS) requires all federally certified laboratories, including waived labs doing point of care testing, to submit COVID-19 test results (for each individual tested) to the Department of Health within 24 hours of results being known or determined. Laboratories and waived labs MUST report all positive, negative, and indeterminate test results for Florida residents.

Reporting must comply with the State of Florida Department of Health (DOH) directives as stated in DOH Emergency Order 20-013, including electronic submission when possible. If electronic submission has not yet been implemented, results must be reported to the applicable Florida County Health Department in a manual, confidential method.

The Florida DOH also issued a memo on October 9, 2020 regarding reports for Long-Term Care facility residents and staff for both COVID-19 test results to DOH. A recent Factsheet from DOH provides the reporting process; please review the DOH COVID-19 Reporting Portal Registration Factsheet issued October 13, 2020.

In addition and effective immediately, laboratories and waived labs must report their CLIA identification number with all results.

Failure to timely report information by a federally certified laboratory (CLIA) or a CLIA waived laboratory is subject to a civil money penalties of $1,000 for the first day of noncompliance and $500 for each additional day of noncompliance.

AHCA administers the CLIA program on behalf of CMS and will conduct onsite investigations for cases of non-compliance.To request assistance with reporting, please email provider.covid19@flhealth.gov.

COVID-19 Reporting Portal Registration Factsheet 

Example of AAP repayment terms

We highly recommend that providers/suppliers create a way, during the 29 month recoupment period, to track the claims submitted, Medicare reimbursement received, and Medicare reimbursements recouped. This will help you reconcile the payments recouped towards your AAP receivable in your system as they are a part of the payback process.

Yes. Providers and suppliers that received an AAP payment can return the money via a check as long as the amount does not exceed $70M. You can use the return of monies voluntary refund form  with a comment in the "Other" box stating it is for the AAP.

• Repayment Terms for Accelerated and Advance Payments Issued to Providers and Suppliers during Covid-19 Emergency Fact Sheet 

• Accelerated and Advance Payment Repayment & Recovery Frequently Asked Questions 

Source: https://medicare.fcso.com/Coronavirus/0460439.asp

KNG Health Consulting conducted an analysis of Medicare payment data from 2011 to 2018 on outpatient surgical procedures in ASCs and hospital outpatient departments. The analysis estimated historical and potential savings with a focus on total knee replacements.

Five key points:

1. Medicare saved $28.7 billion from 2011 to 2018 from surgeries performed in ASCs instead of hospital outpatient departments. The report projects Medicare will save $73.4 billion from 2019 to 2028, with $12 billion saved in 2028 alone.

2. The percentage of total knee replacement and knee mosaicplasty is expected to grow from 13.4 percent of all procedures in ASCs in 2020 to 18 percent in 2028, a 3.7 percent annual growth. Based on that projection, ASC savings for Medicare total knee replacements would be $2.95 billion from 2020 to 2028.

3. Most of the savings in the last decade are attributed to high-volume procedures, including cataract surgeries and colonoscopies, but the report estimates procedures such as endocrine, cardiovascular and orthopedic surgery will drive most of the $73.4 billion savings through 2028.

4. The following five specialties are expected to save Medicare $1 billion per year by being performed in the ASC:

· Eye and ocular adnexa
· Cardiovascular
· Nervous system
· Digestive system surgery
· Musculoskeletal surgery

5. There are more than 5,800 Medicare-certified ASCs in the U.S., with the most common procedures today being cataract surgery, colonoscopy, upper GI endoscopies and pain management procedures.

Source: https://www.beckersasc.com/asc-coding-billing-and-collections/medicare-to-save-73-4b-with-surgery-in-ascs-through-2028-5-things-to-know.html

https://medicare.fcso.com/PE_Resources/210279.asp

Processing time frames for enrollment applications

Factors affecting total processing times

• PECOS web application -- an electronic enrollment application submitted through the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) website .

Article ID number: A57256 (Florida/Puerto Rico/U.S. Virgin Islands)

LCDs are available through the CMS Medicare coverage database at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx .

What you should know:

1. The coverage is for the Augment Bone Graft and Augment Injectable.

2. Medicare beneficiaries can undergo hindfoot and ankle fusions in either setting now. The facility will receive the incremental cost of Augment.

3. The update was made retroactive to Jan. 1. Procedures that were billed using code C1734 will be eligible for payments.

4. Wright Medical President and CEO Robert Palmisano said, "The update to the transitional pass-through payment in the outpatient setting will help ensure healthcare providers have access to AUGMENT Regenerative Solutions, which offer a clear patient benefit by eliminating the complications of the additional surgery required to harvest autograft that can result in site-specific complications and/or prolonged harvest site pain in some patients."

Source: https://www.beckersasc.com/orthopedics-tjr/cms-to-reimburse-for-regenerative-orthopedic-product-in-ascs.html

Please review this article from the durable medical equipment Medicare administrative contractors (DME MACs) about ordering surgical dressings for your Medicare patients

https://medicare.fcso.com/Coverage_News/0452829.asp

Source: First Coast Service Options Inc

CMS Empowers Patients and Ensures Site-Neutral Payment in Proposed Rule

Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule advances CMS commitment to increasing transparency and lowering drug prices

On July 25, CMS took steps to strengthen the Medicare program with proposed changes to ensure that seniors can access the care they need at the site of care that they choose. In addition, as part of the agency’s ongoing efforts to lower drug prices as outlined in the President’s Blueprint, CMS included a Request for Information on how best to develop a model leveraging authority provided to the agency under the Competitive Acquisition Program (CAP) to strengthen negotiations for prescription drugs.

“Our healthcare system should always put patients first, and CMS today is taking important steps to empower patients and provide more affordable choices and options,” said CMS Administrator Seema Verma. “In line with President Trump and Secretary Azar’s priority to lower drug prices, today’s proposed rule is also an important step towards expanding competition for drug payment in Medicare, in order to get the best deal for patients.”

The proposed policies in the CY 2019 Medicare Hospital OPPS and ASC Payment System proposed rule would help lay the foundation for a patient-driven healthcare system. To increase the sustainability of the Medicare program and improve quality of care for seniors, CMS is moving toward site neutral payments for clinic visits (which are essentially check-ups with a clinician). Clinic visits are the most common service billed under the OPPS. Currently, CMS often pays more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.

If finalized, this proposal is projected to save patients about $150 million in lower copayments for clinic visits provided at an off-campus hospital outpatient department. CMS is also proposing to close a potential loophole through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines.

Additionally, CMS is giving patients more options on where to obtain care, in order to improve access and convenience and ensure that CMS policies are not favoring any particular provider type from the start. The proposed rule aims to address other payment differences between sites of service, so that patients can choose the setting that best meets their needs among safe and clinically appropriate options. For 2019, CMS is proposing to:

• Expand the number of procedures payable at ASCs to include additional procedures that can safely be performed in that setting
• Ensure ASC payment for procedures involving certain high-cost devices parallels the payment amount provided to hospital outpatient departments for these devices
•  Help ensure that ASCs remain competitive by stabilizing the differential between ASC payment rates and hospital outpatient department payment rates

As part of active efforts to reduce the cost of prescription drugs, CMS is issuing a Request for Information to solicit public comment on how best to leverage the authority provided under the CAP to get a better deal for beneficiaries as part of a CMS Innovation Center model. We believe a CAP-based model would allow CMS to introduce competition to Medicare Part B, the part of Medicare that pays for medicines that patients receive in a doctor’s office. Currently, CMS pays the average sales price for these therapies plus an extra add-on payment. A CAP-based model would allow CMS to bring on vendors to negotiate payment amounts for Part B drugs, so that Medicare is no longer merely a price taker for these medicines. We are seeking public comment on how the vendors that CMS brings on could help the agency structure value-based payment arrangements with manufacturers, especially for high-cost products, so that seniors and taxpayers will know that medicines are working before they have to pay.

In 2018, CMS implemented a payment policy to help beneficiaries save on coinsurance on drugs that were administered at hospital outpatient departments and that were acquired through the 340B program—a program that allows hospitals to buy certain outpatient drugs at a lower cost. Due to CMS’s policy change, Medicare beneficiaries are now benefiting from the discounts that 340B hospitals enjoy when they receive 340B-acquired drugs. In 2018 alone, beneficiaries are saving an estimated $320 million on out-of-pocket payments for these drugs. For 2019, CMS is expanding this policy by proposing to extend the 340B payment change to non-excepted off-campus departments of hospitals that are paid under the Physician Fee Schedule.

In response to recommendations from the President’s Commission on Combatting Drug Addiction and the Opioid Crisis, CMS also is proposing to pay separately for certain non-opioid pain management drugs in ASCs; is seeking feedback on evidence to support that other non-opioid alternative treatments for acute or chronic pain warrant separate payment under the OPPS or ASC payment systems; and is proposing to eliminate questions regarding pain communication from the hospital patient experience survey.

As part of its commitment to price transparency, CMS is seeking comment through a Request for Information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for healthcare services and out-of-pocket costs, what data elements would be most useful to promote price shopping, and what other changes are needed to empower healthcare consumers.

In the proposed rule, CMS is releasing a Request for Information to welcome continued feedback on the Medicare program and interoperability. CMS is gathering public feedback on revising the CMS patient health and safety standards that are required for providers and suppliers participating in the Medicare and Medicaid programs to further advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers.

Across all the Fiscal Year and CY proposed Medicare payment rules, we have proposed the elimination of reporting requirements for over 100 measures across the health care delivery system, saving providers more than $175 million over the next two years.

For more information:

·  Proposed Rule

·  Fact Sheet

See the full text of this excerpted Press Release (issued July 25).

Summary

For more details on the appropriate and inappropriate uses of modifier 59, including numerous coding examples, here is the link to the MLN Matters® article SE1418 .

Source: First Coast Service Options

It is the first time that a managed-care plan participating in Florida's statewide Medicaid managed-care program had to return money to the state, according to testimony provided to the Florida Legislature early this year by Beth Kidder, a deputy secretary at the Agency for Health Care Administration.

Simply Healthcare spokesman James Freeman told The News Service of Florida on Friday that the managed-care plan had already made the payment to the state. Agency for Health Care Administration spokeswoman Mallory McManus said the agency hadn't received the payment but was expecting it early next week.

The Legislature in 2011 passed a law that requires most Medicaid patients — from the cradle to the grave — to enroll in HMOs or other managed-care plans. The state pays monthly premiums to managed-care plans to provide care to patients, and the plans are required to provide access to all covered services, regardless of whether the cost of those services exceeds the paid premiums.

To ensure that the plans don't make too much of a windfall, the Legislature included in the law a so-called “achieved savings rebate,” which is established by determining pre-tax income as a percentage of revenues. 

Under the achieved savings rebate, plans are required to return money to the state if their pre-tax incomes exceed certain thresholds. Simply Healthcare had to return $1.8 million based on the amount of money it brought in.

When asked whether the company's excessive income hurt patients, Freeman replied, “Simply Healthcare is committed to providing access to quality, affordable services and we continually support efforts that are in the best interest of the health and well-being of our members and the entire community. “

Simply Healthcare has participated in the statewide Medicaid managed-care program since the program's inception. The state is in the process of contracting again with managed-care plans. Simply Healthcare is one 10 plans that have indicated interest in providing Medicaid services statewide.

The Agency for Health Care Administration notified Simply Healthcare on Nov. 2 that it needed to return the $1.8 million, according to agency spokeswoman Shelisha Coleman.

Source: Health News Florida

http://health.wusf.usf.edu/post/medicaid-plan-required-return-18-million-state#stream/0

Modified: 8/14/2017Location: FL, PR, USVILine of Business: Part B

This article provides information and resources from the durable medical equipment Medicare administrative contractors regarding the ordering and supplying of diabetic shoes.

Source: First Coast Service Options

Physicians! Are You Ordering Diabetic Shoes for Your Patients?

Source: CGS Administrators, LLC. 

The following section outlines roles of various practitioners that are involved in the decision-making and provision process for Diabetic Shoes:

• Certifying Physician: The practitioner actively treating and managing the patient's systemic diabetic condition. This practitioner must be an M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy) as outlined in the Social Security Act §1861(s) (12).
• Prescribing Practitioner: The Certifying Physician, a different MD or DO, physician's assistant (PA), nurse practitioner NP), clinical nurse specialist (CNS), or podiatrist (DPM). One of these practitioners may conduct the foot exam and write the detailed written orders required for Medicare's coverage of Therapeutic Shoes for Persons with Diabetes if the Certifying Physician does not complete the foot exam.
• Supplier: The person or entity that provides the shoes and/or inserts to the Medicare beneficiary and bills the Medicare program. A supplier may be a podiatrist, pedorthist, orthotist, prosthetist or other qualified individual. The Prescribing Practitioner may be the supplier.

Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:

1. The beneficiary has diabetes mellitus (Reference diagnosis code section in Policy Article (A52501)); and
2. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions:
   1. Previous amputation of the other foot, or part of either foot, or
   2. History of previous foot ulceration of either foot, or
   3. History of pre-ulcerative calluses of either foot, or
   4. Peripheral neuropathy with evidence of callus formation of either foot, or
   5. Foot deformity of either foot, or
   6. Poor circulation in either foot; and
3. The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes. The Certifying Physician must:
   • Have an in-person visit with the beneficiary during which diabetes management is addressed within six months prior to delivery of the shoes/inserts; and
   • Sign the certification statement on or after the date of the in-person visit and within three months prior to delivery of the shoes/inserts.
4. Prior to selecting the specific items that will be provided; the supplier must conduct and document an in-person evaluation of the beneficiary.
5. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and inserts and document the results.

The Certifying Physician must either:

1. Personally document one or more of the qualifying foot conditions above in the medical record of an in-person visit within six months prior to delivery of the shoes/inserts; or
2. Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D. or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within six months prior to delivery of the shoes/inserts. In this scenario, a different practitioner conducts the foot examination.

The certification statement must be completed on or after the date of the in-person visit and within three months prior to delivery of the diabetic shoes by the supplier. The documentation in the medical record must support the information on the certification statement. The certification statement by itself is not sufficient to meet the required documentation in the medical record and must be corroborated by the medical record.

Just a few reminders:

• The Certifying Physician must be an MD or DO that is managing the beneficiary's systemic diabetic condition.
• Another practitioner may conduct the foot exam that includes evidence of at least one of the qualifying foot issues. If this happens, the Certifying Physician must obtain a copy of that medical record, indicate agreement, sign and date it.
• The certification statement must be completed within three months of delivery of the diabetic shoes.
• The Diabetic Shoe benefit is an annual benefit. Medicare will consider payment for one pair of diabetic shoes and up to three pairs of inserts per calendar year.
• The supplier must have valid detailed written orders in their possession prior to submitting the claim to the DME MAC

All orders and medical records must meet CMS Signature Requirements.

Following this guidance will help your patients and the Medicare program by verifying there is medical documentation to support the provisions for Therapeutic Shoes for Persons with Diabetes, allow your patients to receive the items needed to treat their diabetic condition, and allow Medicare to pay claims appropriately.

Local Coverage Determinations for Therapeutic Shoes for Persons with Diabetes (L33369):

• Jurisdiction A
• Jurisdiction B
• Jurisdiction C
• Jurisdiction D