Archives: Other CMS Developments

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CMS Ends Temporary Suspension of Hospital “Two-Midnight” Short Stay Reviews

CMS has announced that it is allowing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) to resume initial patient status reviews to determine the appropriateness of Part A payment for short stay inpatient hospital claims, effective September 12, 2016.  Such reviews had been “paused” since May 4, 2016 to promote consistent application of … Continue Reading

CMS Announces Flexibility for Physician First-Year Participation in MACRA Quality Payment Program

In a recent blog post, CMS Acting Administrator Andy Slavitt announced CMS’s plans to give physicians more options for complying with significant upcoming changes to Medicare physician fee schedule (MPFS) rules – which will help physicians avoid triggering a negative payment adjustment in the first year of the program. As previously reported, the Medicare Access … Continue Reading

CMS Posts PAMA Clinical Lab Fee Schedule Data Reporting Template and User Guide

In order to assist the clinical laboratory community in meeting new Medicare reporting requirements under the Protecting Access to Medicare Act of 2014 (PAMA), CMS has posted a Clinical Laboratory Fee Schedule Data Reporting Template and a “Quick User Guide” to the template.  By way of background, PAMA requires CMS to base Medicare clinical laboratory fee … Continue Reading

DMEPOS Bidding Round 1 2017 Single Payment Amounts Announced

CMS has announced the single payment amounts 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.  Round 1 2017 contracts will apply … Continue Reading

CMS Seeks Input on “Evolution” of State Innovation Models Initiative, Including Potential Inclusion in MACRA Advanced Alternative Payment Models (APMs)

CMS is soliciting public input on the “evolution” of its State Innovation Models (SIM) Initiative, which was launched in 2013 to accelerate state design and testing of multi-payer payment and delivery models to generate savings and improve care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. In a September 8, 2016 press release, … Continue Reading

CMS Posts Corrections to July 2016 DMEPOS Fee Schedule Rates

CMS has identified errors in its July 2016 update to Medicare durable medical equipment (DME) prosthetic orthotics and supplies (DMEPOS) fee schedule amounts for certain items in non-competitive bidding areas. According to an announcement on the CMS web page, the fee changes resulting from the corrections range from a 4% decrease to a 3% increase, … Continue Reading

CMS Announces Changes to Medicare Advantage Value-Based Insurance Design Model

CMS is announcing changes to the Medicare Advantage Value-Based Insurance Design (MA-VBID) model, which is testing how MA plans can use health plan design elements (e.g., supplemental benefits, disease management, or reduced cost sharing) to encourage enrollees with specified chronic conditions to use high-value clinical services or high-value providers that improve quality of care while … Continue Reading

CMS ICD-10 Coding Flexibility Policy to End October 1, 2016. Period.

On October 1, 2016, CMS is definitively ending an ICD-10 coding “flexibility” policy announced last year that prevents practitioner Medicare Part B physician fee schedule claims from being denied based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/practitioner uses a valid ICD-10 code from the right family.  According to … Continue Reading

CMS Announces Changes to HHA/Ambulance Supplier Enrollment Moratoria, New Exception Process Demo

CMS has announced a number of changes to its temporary Medicare enrollment moratoria for certain provider types in select geographic areas as a mechanism to address fraud, waste, and abuse. First, CMS is extending for six months and expanding statewide its current moratoria on the enrollment of new Medicare Part B nonemergency ground ambulance suppliers … Continue Reading

CMS Selects Regions for Primary Care Innovation Model

CMS has opened the application period for physician practices interested in participating in its new primary care model, Comprehensive Primary Care Plus (CPC+), which is intended to improve how primary care is delivered and reimbursed. CMS also announced that the following 14 regions have been selected to participate in CPC+ (statewide unless otherwise noted): Arkansas; … Continue Reading

CMS’ Web Portal: Final Rule 21 CFR § 411.39 Promises Quick and Efficient Conditional Payment Resolution for Those Able to Abide by Its Strict Guidelines

The Centers for Medicare & Medicaid Services (CMS) has published its long-awaited final rule entitled “Medicare Program: Obtaining Final Medicare Secondary Payer Conditional Payment Amounts via Web Portal.” From the outset of litigation, a plaintiff who is a Medicare beneficiary (or his or her attorney) must report a pending claim to CMS.  This allows Medicare … Continue Reading

CMS Guidance Addresses Impact of Value-Based Purchasing on Medicaid Drug Rebates

CMS has received questions from manufacturers regarding whether price concessions and services offered to payers within Value-Based Purchasing (VBP) arrangements in the pharmaceutical marketplace could impact their drug’s Medicaid best price and increase their Medicaid rebate obligations.  In recent guidance, CMS notes that, in general, prices included in best price include all prices, such as … Continue Reading

CMS to Slash Medicare DMEPOS Rates on July 1, 2016

CMS has released the July 1, 2016 update to Medicare durable medical equipment (DME) prosthetic orthotics and supplies (DMEPOS) fee schedule amounts in non-competitive bidding areas, reflecting full implementation of 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 … Continue Reading

CMS Steps Up Efforts to Recover Overpayments from Providers/Suppliers Sharing TINs

CMS has just announced that it has enhanced its financial accounting system to allow it to recover Medicare payments made to a provider or supplier that shares the same Tax Identification Number (TIN) with a provider or supplier with an outstanding Medicare overpayment across multiple states within a Medicare Administrative Contractor jurisdiction.  CMS implemented this … Continue Reading

CMS Update on Temporary “Two Midnight” QIO Review Pause

CMS has temporarily “paused” Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) performance of initial patient status reviews under CMS’s “two-midnight policy” for short hospital stays. The pause, which took effect May 4, 2016, was a result of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy and was intended to give CMS … Continue Reading

As CMS Gears Up for Latest Round of DMEPOS Competitive Bidding, OIG Faults CMS Vetting of Winning Suppliers’ Licensure Status

CMS recently released the names of the new contract suppliers under the Round 2 Recompete of the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program and the national mail-order competition for diabetes supplies. The CMS announcement was followed shortly by release of an HHS Office of Inspector General (OIG) report that … Continue Reading

CMS Releases Nursing Home Action Plan for 2016/2017

The CMS Survey and Certification Group has released its 2016/2017 Nursing Home Action Plan, which details the agency’s strategy for continuing to improve nursing home quality. The plan focuses on five strategies for quality improvement: (1) enhancing consumer awareness and assistance; (2) strengthening survey processes, standards, and training; (3) improving enforcement activities; (4) promoting quality … Continue Reading

CMS Announces July 18 Public Meeting on 2017 Medicare Clinical Lab Fee Schedule

CMS has scheduled a July 18, 2016 public meeting on payment for new and substantially revised clinical diagnostic laboratory test codes for payment under the 2017 Medicare clinical laboratory fee schedule (CLFS).  The meeting also will address reconsideration requests regarding final determinations made last year. Registration will open on June 6, 2016, and the deadline for presenter registration and submission … Continue Reading

CMS Announces Major Multi-Payer Comprehensive Primary Care Plus (CPC+) Model

CMS has launched a new “Comprehensive Primary Care Plus” (CPC+) model to improve how primary care is delivered and reimbursed. According to CMS, the CPC+ initiative (which builds on the ongoing Comprehensive Primary Care model) will provide “greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower … Continue Reading

CMS Delays Enforcement of Medicaid AMP Rules for 5i Drugs until July 1, 2016

CMS has announced that it is delaying until July 1, 2016 enforcement of new rules regarding the determination of the average manufacturer price (AMP) for inhalation, infusion, instilled, implanted or injectable drugs (“5i drugs”) that are not generally dispensed through retail community pharmacies. The 5i policy, which was included in CMS’s February 1, 2016 Medicaid … Continue Reading

CMS Issues Final 2017 Medicare Advantage Capitation Rates and Medicare Advantage/Part D Payment Policies

CMS has issued its final 2017 Medicare Advantage (MA) and Part D Rate Announcement and Call Letter, which includes a series of policy and payment changes related to these programs. CMS estimates that the final policies will increase MA rates by an average of 0.85%, down from the expected 1.35% increase in the advance notice … Continue Reading

CMS Moving Ahead on Medicare Physician Payment Reform; Proposed MACRA Rule at OMB

The White House Office of Management and Budget (OMB) is now reviewing a highly-anticipated Centers for Medicare & Medicaid Services’ (CMS) proposed rule to implement major Medicare physician payment reform provisions included in the Medicare Access and CHIP Reauthorization Act (MACRA).  As previously reported, MACRA repealed the Medicare sustainable growth rate (SGR) formula and directed … Continue Reading
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