02/19/2019

Important Oncology Related News

WPS Medicare High Dollar Reviews

A little good news for our MSHO membership! WPS Medicare alerted MSHO today that they have turned off the High Dollar Claim edits. You will no longer be asked to submit data, pre-payment, on High Dollar Claims effective immediately.  

Claims that are currently “in” the edits will still need to be worked, so if you have a request, submit the data. Going forward you will no longer receive High Dollar Claim documentation requests!

WPS stated they would be publishing this update for providers soon. In the meantime, if you have any questions related to this alert, please email us at billing@msho.org.

MIPS 2019 Payment Adjustment Confusion

Practices have reported that they are receiving MIPS adjustments on not just their Physician Fee Schedule services but also on their Part B drugs!  Both ASCO and COA are looking into this issue and have found conflicting information.  

Remember, the adjustments in 2019 are based on services from 2017.  We've been told for services in 2017 - Part B Drugs were still considered for the Adjustment.  Beginning in 2018 - they carved that out (Act of Congress - Final Rule)
 
"Beginning with the 2018 performance year, the MIPS payment adjustment percentage will be applied only to Medicare Part B “covered professional services”. That means, most prominently, no MIPS payment adjustment for Part B drugs."

However, CMS released a Fact Sheet where it states:

Application of Payment Adjustments - Payment adjustments will only apply to payments made for covered professional services for which payment is made under, or is based on, the Medicare Physician Fee Schedule and are furnished by a MIPS eligible clinician. The payment adjustment will not apply to Medicare Part B drugs or other items and services that are not covered professional services. The payment adjustment is applied to the Medicare paid amount, so it does not impact the portion of the payment that a beneficiary is responsible to pay.  (CLICK HERE to view fact sheet)

So, is it your money or should you be expecting a CMS take back for these payments?  The answer is unknown at this time and hopefully this will be addressed very soon!

CMS proposes Coverage with Evidence Development for Chimeric Antigen Receptor (CAR) T-cell Therapy

February 15, 2019 - Proposed decision would provide nationwide consistency in CMS’s coverage of the innovative new cancer therapy, to improve patient access and ensure appropriate evidence generation

Today the Centers for Medicare & Medicaid Services (CMS) proposed to cover FDA-approved CAR T-cell therapy, which is a new form of cancer therapy that uses a patient’s own immune system to fight the disease, under “Coverage with Evidence Development” (CED). Currently, there is no national Medicare policy for covering CAR T-cell therapy, so local Medicare Administrative Contractors have discretion over whether to pay for it.  READ MORE