Archives: Other CMS Developments

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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

CMS Delays Enforcement of Medicare Part D Prescriber Enrollment Requirement Until February 1, 2017

CMS is delaying until February 1, 2017 enforcement of previously-adopted regulations that require physicians and other eligible professionals who prescribe Part D drugs to be enrolled in Medicare (or have a valid opt-out affidavit on file) for their prescriptions to be covered under Medicare Part D. CMS is delaying enforcement so that it “minimizes the … Continue Reading

CMS Announces Single Payment Amounts for July 1, 2016 DMEPOS Competitive Bidding Contracts

CMS has just released the single payment amounts for the Round 2 Recompete of the Medicare DMEPOS competitive bidding program and the national mail-order competition for diabetes supplies.  In today’s announcement, CMS stated it will be offering 12,181 contracts to 637 Round 2 Recompete bidders, along with 9 contracts for the national mail-order program for … Continue Reading

CMS Finalizes 2017 Requirements for ACA Marketplace Plans

CMS has published its annual Notice of Benefit and Payment Parameters, which governs participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017.  The sweeping rule addresses protection of consumers enrolled in Marketplace plans, network adequacy, marketplace premium stabilization programs, and various other refinements to Marketplace requirements.  Major provisions of the rule include … Continue Reading

CMS Extends EHR Incentive Program Hardship Application Deadline to July 1, 2016

CMS is allowing eligible professionals, eligible hospitals, and critical access hospitals to apply for Medicare Electronic Health Record (EHR) Incentive Program hardship exceptions until July 1, 2016 to avoid adjustments to their Medicare payments in 2017.  The hardship exception application form is posted on the CMS website.    … Continue Reading

CMS Announces Plan for Medical Review of Therapy Claims Above $3,700 Threshold

CMS has released information about its plans for implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provisions regarding the manual medical review process for outpatient therapy services over the annual threshold. By way of background, the Medicare program has an annual limit on the amount of expenses a patient can accrue for outpatient … Continue Reading

CMS Proposes Rate, Policy Updates for Medicare Advantage and Prescription Drug Plans

CMS has issued its draft 2017 Medicare Advantage (MA) and Part D Advance Notice and Draft Call Letter, which includes a variety of proposed policy changes and rate updates related to these programs. CMS estimates that the draft policies would increase MA rates by an average of 1.35% (considering coding trends the agency expects revenues … Continue Reading
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