Medicare Update

Top Ten Medicare Update Blog Posts in October 2009

Below are the top ten Medicare Update posts during October 2009 (based on the number of views):

1)   CMS Announces 2010 Medicare Premiums and Deductibles

2)   OIG Work Plan Reveals Possible Risk Areas for Medicare Providers and Suppliers

3)   Senator Stabenow Introduces Medicare Physician Fairness Act of 2009

4)   OIG Work Plan Identifies Possible Areas of Concern for Home Health Agencies and DMEPOS Suppliers

5)   CMS Directs Medicare Contractors to Take Action on OIG Reports

6)   CMS Posts FAQ on Code 432 and Medicare Recovery Audit Contractors

7)   The Changing Dynamics of Medicare Fraud Schemes?

8)   Medicare Fraud and Recovery Audit Contractor Program

9)   CMS to Shelve Medicare Medical Home Demonstration

10) Region D Recovery Audit Contractor Updates CMS Approved Audit Issues

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

CMS Directs Medicare Contractors to Take Action on OIG Reports

The Centers for Medicare & Medicaid Services (CMS) recently issued Transmittal 574 and alerted various Medicare contractors (including Part A/B Medicare Administrative Contractors) about 4 Department of Health and Human Services' Office of Inspector General reports (OIG Reports).

Among other things, Transmittal 574 instructs certain Medicare contractors to "review the claims data particularly for services mentioned in the OIG reports" and "take appropriate action consistent with their individual prioritized strategy (e.g., establish automated prepayment edits, develop pre and postpayment reviews, educate physicians/suppliers), if the data warrants any action." 

Transmittal 574 has an effective/implementation date of November 9, 2009.

The OIG Reports identified in Transmittal 574 are set forth below.

• Medicare Part B Chemotherapy Administration: Payment and Policy (OEI-09-08-00190)
• Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services (OEI-09-06-00430)
• Inappropriate Medicare Payments for Chiropractic Services (OEI-07-07-00390)
• Medicare Part B Billing for Ultrasound (OEI-01-08-000100)

Certain Medicare providers and suppliers may want to take a look at the OIG Reports.

Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook.

UPDATE: CMS Releases Proposed Medicare Physician Fee Schedule Changes for 2010

On July 1, 2009, the Centers for Medicare & Medicaid Services (CMS) released a display copy of the Proposed Rule, which is intended to update the payment policies and rates for the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2010.

According to the Proposed Rule, CMS estimates a physician fee schedule update of -21.5 percent for CY 2010.  MPFS rates are updated annually based on a formula that includes the application of the sustainable growth rate (SGR). The formula has resulted in negative updates since CY 2002.  However, Congress has typically enacted legislation each year to avoid the negative updates.

Interestingly, CMS proposes removing physician-administered drugs from the definition of "physician services" in the Proposed Rule for purposes of computing the SGR and the levels of allowed and actual expenditures in all future years. CMS does not expect for such a change to impact the estimated -21.5 percent physician fee schedule update for CY 2010. However, CMS believes that it would reduce the number of years in which physicians are expected to experience a negative update.

In brief, the Proposed Rule also proposes to (among other things):

• Implement provisions of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), including provisions involving cardiac rehabilitation services, pulmonary rehabilitation services, and kidney disease patient education services.
• Clarify an aspect of the "stand in the shoes" provisions of Stark self-referral regulations.
• Implement MIPPA provisions regarding damages related to the delay of the DMEPOS competitive bidding program for suppliers awarded contracts.
• Adopt changes to address concerns raised by MedPAC and GAO about the growth of high cost imaging services and implement a MIPPA requirement that (beginning January 1, 2012) suppliers of the technical component of advanced imaging services be accredited by designated accreditation organizations (AO) and use quality standards developed by the AOs.
• Implement changes to the Physician Quality Reporting Initiative (PQRI) and E-Prescribing Incentive Program for CY 2010.

In fact, CMS has released a Fact Sheet highlighting the Proposed Rule changes to the PQRI and E-Prescribing Programs. See the CMS Press Release and Fact Sheet for more details.

CMS reports that it will be accepting comments on the Proposed Rule until August 31, 2009.  The Proposed Rule is scheduled to appear in the Federal Register on July 13, 2009.  See the Proposed Rule for instructions regarding the submission of comments.

As usual, over the next few days and weeks, more issues and important information will emerge about the Proposed Rule as it is examined in more detail.

UPDATE: The Proposed Rule (as it appears in the Federal Register) can be found here.  CMS has also released a correction to the Proposed Rule, which can be found here.

OIG Reports on Inappropriate Medicare Payments for Chiropractic Services

On May 6, 2009, the Department of Health and Human Services' Office of Inspector General (OIG) released a reported entitled "Inappropriate Medicare Payments for Chiropractic Services."

In the report, the OIG examined 2006 chiropractic claims for beneficiaries receiving more than 12 services from the same chiropractor.  The objective of the review was to determine the extent to which:

• Such services were appropriate.
• Controls ensured that chiropractic claims were not for maintenance therapy.
• Claims data can be used to identify maintenance therapy.
• Chiropractic claims were documented as required.

According to the report, the OIG found that:

• Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47 percent of claims meeting the OIG's study criteria.
• Efforts to stop payments for maintenance therapy have been largely ineffective.
• Claims data lacks initial visit dates for treatment episodes, hindering the identification of maintenance therapy.
• Chiropractors often do not comply with the Medicare Benefit Policy Manual documentation requirements.

According to the report, the OIG recommends that the Centers for Medicare & Medicaid Services:

• Implement and enforce policies to prevent future payments for maintenance therapy.
• Review treatment episodes rather than individual chiropractic claims to strengthen the ability of the CERT to detect errors in chiropractic claims.
• Ensure that chiropractic claims are not paid unless documentation requirements are met.
• Take appropriate action regarding the undocumented, medically unnecessary, and miscoded claims identified in the OIG's sample.

The report indicates that CMS agreed with the second recommendation, did not agree or disagree with the first or third recommendations, and stated that it would instruct contractors to take any necessary corrective actions with respect to the sampled claims that the OIG identified as being in error.