Knowledge Base Category -
Compliance Education Updates
March 2024: MLN8659122: MLN Fact Sheet Original Medicare vs. Medicare Advantage Updated
CMS updated the payment rules for patients enrolled in Medicare Advantage Organizations. https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf
April 2024: MLN Educational Tool Medicare Preventive Services Revised
CMS has revised this tool to clarify social determinants of health information, add a link to the most current and comprehensive list of ICD-10 codes for bone mass measurement and colorectal cancer screening, add coding, coverage, and payment information for COVID-19 vaccine and administration, and replace Hepatis B information with a link to the Hepatitis B screening service. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html
Other Updates
March 26, 2024: GAO Improper Payments: Information on Agencies’ Fiscal Year 2023 Estimates
In this report the Government Accountability Office (GAO) indicates the importance of this information due to the fact that “improper payments – those that should not have been made or were made in the incorrect amount – have consistently been a government-wide issue. Since fiscal year 2003, cumulative improper payment estimated by executive branch agencies have totaled about $2.7 trillion. Reducing improper payments is critical to safeguarding federal funds.” With an estimated $51 billion in estimated improper payments HHC’s Medicare (Medicare Fee-for-Service (Parts A and B), Medicare Advantage (Part C), and Medicare Prescription Drug (Part D)) had the highest estimated improper payments across 14 government agencies.
March 27, 2024: CMS Releases FY 2025 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1804-P)
CMS is proposing to update payment rates by 2.8 percent. This proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, associated impact analysis, and IRF Quality Reporting Program (QRP). Also included are two requests for information (RFIs) (1) Future Measure Concepts for the IRF QRP, and (2) Creating and IRF QRP Star Rating System.
CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1804
CMS Proposed Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/rules-related-files/cms-1804-p
IRF QRP webpage: https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility
March 28, 2024: CMS Issues 3 FY 2025 Proposed Rules: SNF, Inpatient Psych and Hospice
FY 2025 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1802-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-25-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1802-p
FY 2025 Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Quality Reporting (IPFQR) Updates Proposed Rule (CMS-1806-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-medicare-inpatient-psychiatric-facilities-prospective-payment-system-ipf-pps-and
- Of note, CMS has proposed to increase the per treatment amount for electroconvulsive therapy (ECT) from the current FY 2024 payment per treatment of $385.58 to $660.30. CMS believes this increase would help ensure that patients who need ECT are more able to access it. (ECT CPT 90870)
FY 2025 Hospice Payment Rate Update Proposed Rule (CMS-1810-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2025-hospice-payment-rate-update-proposed-rule-cms-1810-p
Beth Cobb
Medicare MLN Articles
March 20, 2024: MLN MM11003: Electronic Medical Documentation Requests via the Electronic Submission of Medical Documentation System – Revised
This MLN was first released February 1, 2019. In the March 20, 2024 revision to this article, CMS has added information about the implementation of a new feature to accept review outcome letters during October 2023 release. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf
April 4, 2024: MLN MM13577: Ambulatory Surgical Center Payment Update – April 2024
Make sure your billing staff knows about new CPT and HCPCS codes, Device code changes, iDose TR (travoprost intracameral implant) for the treatment of glaucoma, Drug and biological code changes, and Skin code updates. https://www.cms.gov/files/document/mm13577-ambulatory-surgical-center-payment-update-april-2024.pdf
April 15, 2024: MLN MM13574: DMEPOS Fee Schedule: April 2024 Quarterly Update – Revised
This MLN article was revised on April 15th to show the addition of 4 HCPCS Level II codes to Common Working File category 58. CMS also revised the effective date and the web address of Change Request (CR) 13574). https://www.cms.gov/files/document/mm13574-dmepos-fee-schedule-april-2024-quarterly-update.pdf
April 15, 2024: MLN MM13587: Medicare Claims Processing Manual Update: Inpatient Rehabilitation Facility
CMS advised that you make sure your billing staff know that hospitals may open a new IRF unit at any time during the cost reporting year, and any IRF unit excluded during a cost reporting Year will stay excluded for the rest of the cost reporting year. https://www.cms.gov/files/document/mm13587-medicare-claims-processing-manual-update-inpatient-rehabilitation-facility.pdf
Coverage Updates
April 15, 2024: CMS Releases Fact Sheet for Potential NCD for Preexposure Prophylaxis (PrER) Using Antiretroviral Drugs to Prevent HIV
CMS is sharing this information to encourage pharmacies and other interested parties to prepare for a potential National Coverage Determination (NCD) for PrEP Using Antiretroviral Drugs to Prevent HIV.
- National Coverage Analysis (NCA) Tracking Sheet: https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?NCAId=310
- CMS Fact Sheet: https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf
April 16, 2024: MLN MM13512: National Coverage Determination 20.7: Percutaneous Transluminal Angioplasty
This article provides education about the changes in coverage for PTA of the carotid artery concurrent with stenting effective October 11, 2023:
- Patients don’t have to enroll in a clinical trial.
- Facilities don’t need CMS approval to perform this service.
- You must engage in a formal shared decision-making (SDM) process with the patient. This must include documentation of four key elements outlined in this MLN article.
- MACs can decide if this service is covered if it’s not addressed in this NCD.
Note, your MAC will adjust claims processed in error that you bring to their attention. https://www.cms.gov/files/document/mm13215-national-coverage-determination-207-percutaneous-transluminal-angioplasty.pdf
Beth Cobb
Did You Know?
In mid-February CMS announced a new Prior Authorization Demonstration for certain Ambulatory Surgical Center (ASC) Services.
Why It Matters?
In their announcement, CMS references the nationwide prior authorization process for certain hospital outpatient department (OPD) services that was finalized in the Calendar Year 2020 OPPS Final Rule and implemented on July 1, 2020. The initial services subject to prior authorization in 2020 were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.
This 5-year demonstration project design will include ASC providers that:
- Submit claims with place of service 24 (Ambulatory Surgical Center) for one of the five previously mentioned services,
- Are in one of the ten demonstration states (California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York), and
- Submit claims to Medicare fee-for-service.
CMS plans to implement this demonstration for all ten states in one phase and they do not anticipate beginning the demonstration earlier than the fall of 2024.
Why now? CMS indicates that data from 2019 to 2021 shows there has been a significant increase in utilization in the ASC for the above five services and they were selected “for inclusion in this demonstration, based upon problematic events, data, trends, and potential billing behavior impacts of the OPD Prior Authorization Program which requires prior authorization as a condition of payment for these services.”
What Can You Do?
Take the time to read CMS Form CMS-10884 to learn about details of the demonstration design and justification for the need for this demonstration.
Since “the documentation requirements that MACs already have for the services in the OPD program, including local coverage determinations (LCDs), are applicable to these ASC services as well” visit your MACs website to find related resources. For example, Palmetto GBA Jurisdiction J (JJ), the MAC for Tennessee and Georgia has several resources available on their Medical Review / Outpatient Prior Department Prior Authorization (PA) webpage (i.e., Blepharoplasty and Medical Necessity Module).
Finally, if you are in one of the demonstration states, share this information with key stakeholders at your facility.
Beth Cobb
March 4, 2024: MLN MM13449: Stay of Enrollment
Make sure your staff knows about a new provider enrollment status called a stay of enrollment and updates to the Medicare Program Integrity Manual, Chapter 10. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf
March 7, 2024: MLN MM13546: New Waived Tests
Make sure your billing staff is aware of the Clinical Laboratory Improvement Amendment (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13546-new-waived-tests.pdf
March 14, 2024: MLN MM13548: Medicare Claims Processing Manual Updates – HCPCS Billing Codes & Advance Beneficiary Notice of Non-coverage Requirements
Make sure your staff knows the HCPCS codes to bill and what CPT codes to not bill for an initial preventive physical exam (IPPE) and annual wellness visit (AWV) services. CMS also includes information about providing a patient an Advanced Beneficiary Notice of Non-coverage (ABN) in this article. https://www.cms.gov/files/document/medicare-claims-processing-manual-updates-hcpcs-billing-codes-advance-beneficiary-notice-non.pdf
March 18, 2024: MLN MM13554: Changes to the Laboratory National Coverage Determination Edit Software: July 2024 Update
Make sure your billing staff knows about newly available codes, recent coding changes, and how to find NCD coding information. Relevant laboratory NCD coding with changes July 2024 includes NCD 190.18 (Serum Iron Studies), 190.21B (Glycated Hemoglobin/Glycated Protein), and 190.31 (Prostate Specific Antigen). https://www.cms.gov/files/document/mm13554-changes-laboratory-national-coverage-determination-edit-software-july-2024-update.pdf
March 21, 2024: Transmittal R12552CP: April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)
This Recurring Update Notification (RUN) provides instructions on coding changes and policy updates that are effective April 1, 2024, for the Hospital OPPS. Updates include coding and policy changes for new services, pass-through drug, and devices, eleven new Proprietary Lab Analysis (PLA) codes and other items and services, for example payment for intensive cardiac rehabilitation services (ICR) provided by an off-campus, non-excepted provider-based department (PBD) of a hospital.
In the CY 2024 OPPS/ASC final rule, CMS excluded ICR from the 40 percent Physician Fee Schedule Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (ICR; with or without continuous ECG monitoring with exercise, per session) and G0423 (ICR; with or without continuous ECG monitoring without exercise, per session). “Under this change 100 percent of the OPPS rate for ICR is paid irrespective of the presence of the PN modifier on the claim…please not that claims for HCPCS A0422 and G0433 submitted with the PN modifier from January to April 2024 were paid at the 40 percent rate. However, upon the April IOCE release, an additional amount will be retroactively applied to these past claims so that they are paid at 100 percent of the OPPS rate.” https://www.cms.gov/files/document/r12552cp.pdf
Beth Cobb
Did You Know?
According to the American Cancer Society, there has been a rise in colorectal diagnoses among people 50 and younger. “In the late 1990s, colorectal cancer was the fourth leading cause of cancer death in both men and women in this age group, and now, it is the first cause of cancer death in men younger than 50 and the second cause in women that age.”
In May 2021, the U.S. Preventive Services Task Force changed its colorectal cancer screening recommendation. They lowered the age at which adults at average risk of getting colorectal cancer begin screening from 50 to 45.
Why it Matters?
Effective January 1, 2023, CMS lowered the minimum age for colorectal screening (CRC) from age 50 to 45 for certain tests.
MLN Matters article MM13017, Removal of a National Coverage Determination and & Expansion of Coverage of Colorectal (CRC) Screening includes:
- A list of the specific screening tests where the minimum age has decreased from 50 to 45 years and older, and
- An expanded definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios.
Also, National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests was revised to reflect the decrease in minimum age for each of the covered indications listed in this policy.
What Can You Do?
As a healthcare provider, be aware of the changes in Medicare’s colorectal screening coverage. Use the Colorectal Cancer Screening Tests information available in MLN Educational Tool Medicare Preventive Services to identify:
- Applicable HCPCS, CPT and ICD-10 Codes,
- The specific screening tests that Medicare Covers,
- The frequency for performing these screening tests for patients not meeting high-risk criteria as well as patients at high-risk,
- What the patient pays, and
- Other notes (i.e., CMS pays for anesthesia services provided in conjunction with, and in support of, a screening colonoscopy reported with CPT code 00812.)
As a healthcare consumer, I encourage everyone to talk with your doctor about your risk(s) for colorectal cancer and the need for screening tests.
References
American Cancer Society article: 2024 – First Year the US Expects More than 2M New Cases of Cancer: https://www.cancer.org/research/acs-research-news/facts-and-figures-2024.html
U.S. Preventive Services Task Force May 18, 2021 Final Recommendation Statement for colorectal cancer screening: https://uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
MLN Educational tool Medicare Preventive Services: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN
Beth Cobb
February 5, 2024: MLN MM13507: ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2024 Update
Make sure your staff knows about newly available codes, recent code changes, and NCD coding information. https://www.cms.gov/files/document/mm13507-icd-10-other-coding-revisions-national-coverage-determinations-july-2024-update.pdf
February 5, 2024: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised
This special edition MLN article was originally released March 26, 2019. With this latest revision, CMS clarified how to hand certain off-campus provider-based departments excepted from Section 603 payment policy. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
February 12, 2024: MLN MM13513: Pulmonary Rehabilitation, Cardiac Rehabilitation, & Intensive Cardiac Rehabilitation Expansion of Supervising Practitioners
Make sure your billing staff knows about updates to the above-mentioned rehabilitation services effective January 1, 2024, including expanding the types of practitioners who may supervise these services. https://www.cms.gov/files/document/mm13513-pulmonary-rehabilitation-cardiac-rehabilitation-intensive-cardiac-rehabilitation-expansion.pdf
February 15, 2024: Limitation on Recoupment of Medicare Overpayments
Limitation on recoupment of Medicare overpayments is during the first and second level of appeal only. Make sure your staff knows about this limit, when to request an extended repayment plan (ERS) or choose immediate recoupment, and how CMS pays interest on overpayments. https://www.cms.gov/files/document/mm11808-limitation-recoupment-medicare-overpayments.pdf
February 21, 2024: MLN MM13485: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: CY 2024 Update
Make sure your billing staff knows about CMS rescinding the AUC program regulations, the program has been paused for reevaluation, and elimination of AUC consultation information on Medicare Fee-for-Service claims. https://www.cms.gov/files/document/mm13485-appropriate-use-criteria-advanced-diagnostic-imaging-cy-2024-update.pdf
February 22, 2024: MLN MM13451: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Make sure your billing staff knows when the next private payor data reporting period is and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13541-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
Beth Cobb
Did You Know?
Through the Medicare Learning Network (MLN), CMS has developed an interactive education tool titled Medicare Preventive Services (MLN006559 January 2024). This tool is meant to help providers properly provide and bill Medicare prevention services (i.e., bone mass measurement, colorectal screening, lung cancer screening).
For each Preventive Service listed in the tool, you will find the following information as applicable to the service:
- National Coverage Determination (NCD),
- HCPCS and CPT codes specific to the service provided,
- ICD-10-CM diagnosis codes,
- Telehealth eligibility,
- Coverage requirements,
- Frequency requirements, and
- Medicare Beneficiary (patient) cost sharing.
You will also find answers to the following questions:
- How do I determine the last date a patient got a preventive service, so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?
- When can CMS add new Medicare preventive services?
- My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?
- CMS provides a link to a Preventive Services Checklist that you can give your patients.
- Note, CMS also highlights preventive services with an apple in the official U.S. government Medicare Handbook, Medicare and You. You will find information about preventive services in the 2024 Edition of this handbook on pages 30-55.
- What’s a primary care setting?
Why It Matters?
This tool was revised in January 2024. Following are two examples of what has been revised:
Annual Wellness Visit
New HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes) has been added as well as the following “Other Notes:”
- The implementation date for SDOH Risk Assessment claims is July 1, 2024,
- The billing HCPCS code is G0136,
- Add modifier 33 to an SDOH, G0136, performed on the same day as the Annual Wellness Visit to waive copayment and deductible,
- G0136 is covered once a year with copayment and deductible waived, and
- The AWV can be an optional community health integration (CHI) initiating visit when the provider identifies any unmet SDOH needs that prevent the patient from doing the recommended personalized prevention plan.
Flu Shot
Starting January 1, 2024, Medicare pays an additional payment for in-home flu shot administration under certain circumstances.
What Can You Do?
- Read all the revisions made to this tool in January in the February 15, 2024 edition of MLN Connects,
- Use this tool to identify service specific applicable coverage requirements (NCD), HCPCS/CPT codes, and ICD-10-CM diagnosis codes, and
- Share this tool with key stakeholders at your facility.
Beth Cobb
Medicare Transmittals & MLN Articles
December 21, 2023: MLN MM13496: Billing Requirements for Intensive Outpatient Program Services under New Condition Code 92
Starting January 1, 2024, CMS requires the use of new condition code 92 on all Intensive Outpatient Program (IOP) claims from hospitals and Community Mental Health Centers (CMHCs). Make sure your billing staff knows about billing this new condition code and Medicare manual changes related to providing IOP services. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf
December 26, 2023: MLN MM13222: New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services
CMS advises that you make sure your billing staff knows about this new code, that an OPPS provider will get paid per diem payments for this service, the intensity of services required for Medicare to cover and pay for this service, and the outpatient settings this billing requirement is applicable to. https://www.cms.gov/files/document/mm13222-new-condition-code-92-billing-requirements-intensive-outpatient-program-services.pdf
January 3, 2024: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update - Revised
This MLN article was revised to change the number of HCPCS codes in Tables 8 and 10 and update the web address of the Change Request (CR) transmittal. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf
January 9, 2024: MLN MM13503: Specimen Collection Fees and Travel Allowance: 2024 Update
This MLN article provides updated information about the specimen collection fees and travel allowances for 2024 and other policy updates and reminders. https://www.cms.gov/files/document/mm13503-specimen-collection-fees-and-travel-allowance-2024-update.pdf
January 10, 2024: MLN MM13488: Hospital Outpatient Prospective Payment System: January 2024 Update
Make sure your billing staff is aware of the system updates effective January 1, 2024, for example:
- COVID-19 vaccine and administration codes,
- Covered devices for pass-through payments,
- Inpatient-only list (IPO) updates, and
- Services: Covered dental rehabilitation procedures, Marriage and Family Therapist (MFT), and Mental health counselor (MHC),
January 16, 2024: MLN MM13264: Billing Requirements for Intensive Outpatient Program Services for Federally Qualified Health Centers and Rural Health Clinics
Make sure your billing staff knows about the Intensive Outpatient Program (IOP) scope of benefits, certification and plan of care requirements, payment policies, and coding and billing requirements. https://www.cms.gov/files/document/mm13264-billing-requirements-intensive-outpatient-program-services-federally-qualified-health.pdf
January 18, 2024: MLN MM13473: How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211
CMS advises that you make sure your billing staff knows about the correct use of HCPCS code G2211 and modifier 25, documentation requirements for G2211, and patient coinsurance and deductible. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf
Related MLN Matters article MM13272 was revised on December 21, 2023. CMS advises in this article that you make sure your billing staff knows about complexity add-on code G2211. https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf
January 18, 2024: MLN MM13480: Refillable DMEPOS Documentation Requirements
Make sure your staff knows about the updated documentation requirements for refillable DMEPOS and the requirement to contact the patient before refilling DMEPOS. https://www.cms.gov/files/document/mm13480-refillable-dmepos-documentation-requirements.pdf
Beth Cobb
Compliance Education Updates
December 2023: MLN Booklet: Global Surgery
CMS has updated this MLN booklet to include the instructions for critical care visits that are unrelated to the surgical procedure and performed post-operatively, report modifier -FY. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
Other Updates
January 18, 2024: CMS Adds Utilization Data on Medicare.gov for the First Time
CMS noted in the Friday January 26 edition of CMS Roundup that they have “added utilization data, specifically procedure volume, for the first time on the Medicare.gov compare tool’s profile pages for doctors and clinicians…this is the latest example of CMS’ transparency efforts to ensure the compare tool on Medicare.gov provides patients and caregivers with information about services they may value as they search for clinicians.”
The dataset is currently published in the Provider Data Catalog. The initial list of procedures includes hip and knee replacement, spinal fusion, cataract surgery, colonoscopy, open hernia repair of the groin, minimally invasive hernia repair, mastectomy, CABG, pacemaker insertion or repair, coronary angioplasty and stenting, and prostate resection.
You can read more about this data release in a CMS Fact Sheet at https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-195-kb.pdf.
January 22, 2024: New EMTALA Resources
CMS announced in a Press Release that they are launching “a series of actions to educate the public about their rights to emergency medical care and to help support the efforts of hospitals to meet their obligations under the Emergency Medical Treatment and Labor Act (EMTALA).” One action CMS has taken is to publish new informational resources on their website at https://www.cms.gov/priorities/your-patient-rights/emergency-room-rights. You can read the entire press release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-actions-help-hospitals-meet-obligations-under-emtala.
New Kepro Email Addresses
In the January 2024 edition of Case Review Connections, Kepro lets providers know that Kepro recently became a part of the Acentra health family, and you may notice some changes in email addresses, moving to acentra.com. They do not anticipate any other changes at this time and will provide guidance in the future of any potential required changes. You can sign up for this newsletter on the Kepro website at https://www.keproqio.com/newsletters.
January 24, 2024: HHS Releases Voluntary Cybersecurity Goals for the Health Sector & New Gateway Website
HHS announced the release of “voluntary health care specific cybersecurity performance goals (CPGs) and a new gateway website to help Health Care and Public Health (HPH) sector organizations implement these high-impact cybersecurity practices and ease access to the plethora of cybersecurity resources HHS and other federal partners offer.” https://aspr.hhs.gov/newsroom/Pages/HHS-Releases-CPGs-and-Gateway-Website-Jan2024.aspx
Beth Cobb
During the first week of 2024, the following information was posted on several of the Medicare Administrative Contractors (MACs) websites.
“On June 15, 2022, the Supreme Court held in American Hospital Association v. Becerra that because CMS had not conducted a survey of hospitals’ acquisition costs, it could not vary the payment rates for outpatient prescription drugs by hospital group. On remand, the U.S. District Court for the District of Columbia prospectively vacated-beginning September 28, 2022- adjustments CMS had made to payments under the Hospital Outpatient Prospective Payment System for drugs acquired through the 340B program.
On January 10, 2023, the U.S. District Court for the District of Columbia issued a remand without vacatur to give the Centers for Medicare & Medicaid Services (CMS) the opportunity to determine the proper remedy for the reduced payment amounts to 340B hospitals under the payment rates in the final OPPS rules beginning in CY 2018 and continuing through September 27, 2022.
Accordingly, on November 8, 2023, CMS published the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022.
Under this final rule, affected hospitals will be paid a one-time lump-sum amount based on the difference between what they were paid for 340B-acquired rugs from CY 2018 through September 27, 2022, and what they would have been paid during this time-period had the 340B Drug Payment Policy never existed. These payment amounts are listed in Addendum AAA to the final rule. This final rule ensures affected hospitals will receive the approximate payment they would have received if the original CY 2018-2022 340B payment policy had never existed.
Beginning January 8, 2024, Medicare Administrative Contractors (MACs) will begin making these one-time lump-sum remedy payments to affected providers via HIGLAS. There payments are scheduled to be completed by February 7, 2024.
The MACs will not included these lump sum payments on any cost report.
All remedy payments are subject to the MAC’s normal accounting procedures and may in effect be combined with other payment released on the same date and/or include any applicable outstanding Medicare offsets that are the result of provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process, any of which may impact the provider’s net payment amount.”
MAC Specific Announcements
Beth Cobb
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