Archives: Other CMS Developments

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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

Medicare Shared Savings Program Applications for January 1, 2016 Start Date

CMS is proceeding with the application process for the Medicare Shared Savings Program for the January 1, 2016 program start date. Applicants interested in participating must submit a Notice of Intent to Apply by May 29, 2015, and complete the application by July 31, 2015.  A CMS call regarding the Shared Savings Program application review process is … Continue Reading

CMS Touts Pioneer ACO Model Savings and Potential Expansion

On May 4, 2015, CMS announced that the Pioneer Accountable Care Organization (ACO) Model generated $384 million in savings to Medicare over two years. Under the Pioneer ACO Model, which was authorized by the ACA, health care organizations and providers with experience coordinating care across settings may share in Medicare savings generated if they meet … Continue Reading

CMS Schedules July 16 Meeting on Medicare Clinical Laboratory Fee Schedule Payments

CMS has just announced that it is holding a public meeting on July 16, 2015 to discuss Medicare clinical laboratory fee schedule (CLFS) payment for new or substantially revised HCPCS codes for calendar year 2016. At the meeting, the public also will have an opportunity to comment on certain reconsideration requests regarding test code payment … Continue Reading

CMS Releases 2016 Medicare Advantage/Part D Drug Plan Rates and Policies

CMS has released the 2016 Medicare Advantage (MA) and Part D Rate Announcement and Call Letter.  According to a CMS fact sheet, the final policies increase Medicare Advantage rates by 1.25% (compared to an earlier forecast of a 0.95% reduction), although considering coding trends the agency expects revenues to increase by 3.25%. In addition, CMS … Continue Reading

CMS Issues First Hospital Compare Star Ratings

CMS is now posting star ratings on Hospital Compare to help consumers assess hospital performance related to patient experience of care. The Hospital Compare star ratings are based on data from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) measures on patients’ perspectives of hospital care, including such topics as: how well nurses … Continue Reading

CMS, FDA Establishing Interagency Task Force on LDT Quality Oversight

CMS and FDA are establishing an interagency task force to reinforce their collaboration regarding the oversight of laboratory-developed tests (LDTs), which are tests intended for clinical use and designed, manufactured, and used within a single lab. According to an FDA blog post, the goals of the FDA/CMS task force include: (1) identifying areas of similarity between … Continue Reading