06/04/2019

CMS-Medicare

Recent Oncology Related Articles

More than Half of All OCM Providers Could Owe CMS Money if Required to Join in 2-Sided Risk Model

The Oncology Care Model (OCM), started in 2016, is a voluntary 5-year bundled-payment program developed by the Center for Medicare & Medicaid Innovation. The OCM encourages practices to improve care and lower costs through episode-based cost performance and quality measures. Currently, all OCM participants are enrolled in a 1-sided risk arrangement. Beginning in July...READ MORE

CMS Takes Action to Lower Prescription Drug Prices and Increase Transparency

On May 16, CMS finalized improvements to Medicare Advantage and Medicare Part D, which provide seniors with medical and prescription drug coverage through competing private insurance plans. These changes ensure that patients have greater transparency into the cost of prescription drugs, so they can compare options and demand value from pharmaceutical companies.

For More Information:

• Final Rule
• Press Release
• Fact Sheet

April – June Quarterly Provider Update

The April – June Quarterly Provider Update is available, including issuances and regulations. Find out about:

• Regulations and major policies currently under development during this quarter
• Regulations and major policies completed or cancelled
• New or revised manual instructions

Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.

Use the following resources to bill correctly:

• IMRT Planning Services Editing MLN Matters Article
• July 2016 Update of the Hospital Outpatient Prospective Payment System MLN Matters Article
• Medicare Claims Processing Manual, Chapter 4, Section 200.3.1
• Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services OIG Report, August 2018

Medicare Shared Savings Program: Submit Notice of Intent to Apply Beginning June 11

CMS announced Notice of Intent to Apply (NOIA) and application cycle dates for a January 1, 2020, start date for the Medicare Shared Savings Program – Pathways to Success. Beginning June 11, 2019, CMS will start accepting NOIAs via the Accountable Care Organization (ACO) Management System (ACO-MS). You must submit a NOIA if you intend to apply to the BASIC or ENHANCED track of the Shared Savings Program, apply for a Skilled Nursing Facility 3-Day Rule Waiver, and/or establish and operate a Beneficiary Incentive Program.

NOIA submissions are due no later than June 28 at noon ET. A NOIA submission does not bind your
organization to submit an application; however, you must submit a NOIA to be eligible to apply. Each ACO should submit only one NOIA. ACOs will have an opportunity to make changes to their tracks, repayment mechanisms, and other NOIA-related information during the application submission period. Also, CMS allows ACOs to submit sample documentation (e.g., sample ACO participant agreements) with their NOIA in order to receive feedback from CMS before the application period opens.

The application submission period will be open from July 1 through 29, 2019, at noon ET.

For More Information:

• Shared Savings Program website
• Application Types and Timeline webpage
• Application Toolkit webpage
• For questions email SSPACO_Applications@cms.hhs.gov

Laboratory Blood Counts: Provider Compliance Tips

In 2017, the Medicare fee-for-service improper payment rate for blood counts was 19.2 percent with projected inaccurate payments of $56.6 million. Improper payments resulted from:

• Insufficient documentation - 89 percent
• Incorrect coding - 8.3 percent
• No documentation - 2.7 percent

Prevent denials by reviewing the Provider Compliance Tips for Laboratory Tests – Blood Counts Fact Sheet, which details coverage and documentation requirements. 

Recent LearnResource & MedLearn Matters Articles

• Claim Status Category and Claim Status Codes Update
• Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
• Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
• Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes
• Proper Use of Modifier 59 — Revised