Archives: Other CMS Developments

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CMS Releases 2016 Medicare DMEPOS Fee Schedule – Reflecting Steep Cuts Based on DMEPOS Competitive Bidding Rates

Today CMS released the Medicare durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) fee schedule for the first half of 2016 – reflecting the agency’s first adjustments to nationwide rates based on DMEPOS competitive bidding program (CBP) pricing. As previously reported, the Affordable Care Act mandates that CMS use pricing information from competitive bidding … Continue Reading

CMS Invites Comments on MACRA Episode Groups

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to establish care episode groups and patient condition groups, which will be used to measure resource use under the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Care episode groups describe the patient’s clinical problems at the time items and … Continue Reading

CMS Update on Medicare-Medicaid Plan Quality Ratings Strategy

CMS has provided an update on vision for developing a star rating system for Medicare-Medicaid Plans (MMPs). While CMS does not expect to have the full star rating system in place during the testing of the previously-announced Financial Alignment Initiative, the rating system could potentially serve as a basis for quality-based payments for plans in … Continue Reading

Medicare FFS RACs Identified Almost $2.4 Billion in Overpayments in FY 2014

According to CMS, the Medicare Fee-For-Service (FFS) Recovery Auditor Program identified and corrected $2.57 billion in improper Medicare payments in FY 2014. The lion’s share of this amount — $2.39 billion — represented overpayments collected, compared to $173.1 million in underpayments repaid to providers. Considering all program costs (other than expenses incurred at the third … Continue Reading

CMS Releases Medicare DMEPOS Payment/Utilization Data

In a continuation of the Administration’s efforts to make Medicare spending data more transparent, CMS has released detailed payment information regarding physicians and other providers who order durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for Medicare beneficiaries.  The new “Referring Provider DMEPOS Public Use File” includes provider-specific Medicare Part B DMEPOS utilization, payment, and … Continue Reading

CMS Announces Medicare Part D Medication Therapy Management Innovation Model

The latest CMS “innovation model” will test whether providing Medicare Part D prescription drug plan (PDP) sponsors with financial incentives and flexibility with regard to medication therapy management (MTM) program requirements can improve quality and reduce costs by “right-sizing” investment in MTM services.  Specifically, CMS will allow stand-alone PDP sponsors in 11 states to apply … Continue Reading

CMS Releases Preliminary 2016 Determinations for New Clinical Lab Tests, Announces October 19 Open Meeting on Clinical Lab Payments

CMS has announced its preliminary 2016 clinical laboratory fee schedule (CLFS) payment determinations for new and reconsidered test codes.  These preliminary determinations will be the subject of an October 19, 2015 meeting of the Advisory Panel on Clinical Diagnostic Laboratory Tests. The public may attend the meeting in-person (registration required), view via webcast, or listen … Continue Reading

CMS Equity Plan Tackles Health Disparities

On September 8, 2015, CMS released its first “CMS Equity Plan for Improving Quality in Medicare,” which seeks to reduce health disparities among Medicare populations that experience disproportionately high burdens of disease, lower quality of care, and barriers accessing care. Such populations identified by CMS include: racial and ethnic minorities, sexual and gender minorities, people … Continue Reading

CMS Launches New Medicare Advantage Innovation Model

The latest CMS “innovation model” focuses on options for redesigning Medicare Advantage (MA) to improve health outcomes while reducing expenditures. Specifically, the Medicare Advantage Value-Based Insurance Design (VBID) Model will allow MA plans in seven states to apply to offer supplemental benefits or reduced cost sharing to enrollees with specified chronic conditions. The five-year initiative will … Continue Reading

CMS Updates Inpatient Hospital “Two Midnight” Review Education/Enforcement Strategy

CMS recently provided an update on its education and enforcement strategies related to its “Two Midnight” policy, which addresses when surgical procedures, diagnostic tests and other treatments are generally considered appropriate for inpatient hospital admission under Medicare Part A. The Medicare Access and CHIP Reauthorization Act of 2015 generally bars recovery audit contractors (RACs) from … Continue Reading

CMS Announces Timeline for the DMEPOS Competitive Bidding Round 1 2017 Competition

On August 11, 2015, CMS announced the detailed timeline for “Round 1 2017” of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. As previously reported, this round represents a recompete (with product category changes) of the current Round 1 Recompete contracts, which expire December 31, 2016. The following are the … Continue Reading

CMS Proposes “Comprehensive Care for Joint Replacement” Model

On July 14, 2015, CMS published a proposed rule to establish a Medicare Comprehensive Care for Joint Replacement (CCJR) model.  Under the proposed rule, CMS would provide a bundled payment to hospitals in selected geographic areas for an episode of care for lower extremity joint replacement (LEJR) surgery, covering all services provided during the inpatient admission … Continue Reading

CMS Announces Efforts to Ease ICD-10 Transition

Today CMS announced steps to help physicians prepare for the switch to ICD-10 coding on October 1, 2015.  Most significantly, CMS announced that during the first year after ICD-10 implementation, Medicare contractors will not deny physician or other practitioner Part B physician fee schedule claims based solely on the specificity of the ICD-10 diagnosis code, … Continue Reading

CMS Proposes HCPCS Changes for Miscellaneous DME

CMS is proposing to revise the coding used to describe miscellaneous durable medical equipment (DME). The agency notes that HCPCS code E1399, “durable medical equipment, miscellaneous,” is currently used to bill for inexpensive DME, other covered DME, and replacement parts, which are subject to different payment rules. Likewise, HCPCS code K0108 describes a “wheelchair component … Continue Reading

CMS Independence at Home Demonstration Yields $25 Million in Savings in First Year

The CMS Independence at Home Demonstration saved more than $25 million during its first performance year while delivering high-quality patient care, according to a June 18, 2015 CMS announcement. The Independence at Home Demonstration is an ACA innovation model testing the effectiveness of delivering comprehensive primary care services at home to Medicare beneficiaries with multiple chronic … Continue Reading

CMS Releases Latest Medicare Hospital and Physician Utilization, Payment Data

CMS has released detailed Medicare inpatient hospital, outpatient hospital, and physician utilization and payment data for 2013, including data analysis such as spending breakdowns by specialty and region. The hospital data set includes average hospital charges, Medicare payment, and utilization statistics for the 100 most common Medicare inpatient diagnosis related groups (DRGs). CMS also released hospital-specific … Continue Reading

CMS Launches New ACA Cardiovascular Risk Reduction Innovation Model

CMS is inviting physician practices to apply to participate in its new “Million Hearts® Cardiovascular Risk Reduction Model," which will test whether encouraging physician practices to calculate risk for eligible Medicare beneficiaries will prevent the occurrence of first-time heart attacks and strokes. CMS intends to operate the model for five years, and seeks to enroll … Continue Reading

CMS Issues Guidance to States on Medicaid/CHIP Provider Fingerprint-Based Criminal Background Checks

On June 1, 2015, CMS provided additional guidance to state Medicaid directors on implementation of fingerprint-based criminal background checks (FCBCs) as a component of ACA Medicare, Medicaid, and CHIP provider screening requirements. CMS stipulates that states have 60 days from the date of the letter to begin implementation of the FCBC requirement, and implementation must be … Continue Reading

CMS Excludes Non-Invasive Pressure Support Ventilators from DMEPOS Competitive Bidding; Announces Related Coding Changes

CMS has removed the non-invasive pressure support ventilators product category from Round 1 2017 of the Medicare DMEPOS Competitive Bidding Program. The agency also is revising the HCPCS coding for ventilators in response to what it characterizes as program abuse related to inappropriate billing of HCPCS code E0464 Pressure Support Ventilators (non-invasive). Specifically, CMS proposes discontinuing … Continue Reading

CMS Guidance on Beneficiary MA Drug Plan Disenrollments by Long Term Care Facilities

CMS has released guidance for long term care (LTC) facilities, including nursing facilities and skilled nursing facilities, on beneficiary disenrollments. According to the guidance, “CMS continues to see an unacceptable practice of LTC facilities disenrolling beneficiaries from Medicare Advantage prescription drug plans (MAPDs) and enrolling them into stand-alone drug plans (PDPs) without the beneficiary’s or … Continue Reading