Knowledge Base Article

Compliance Education Updates

March 2024: MLN8659122: MLN Fact Sheet Original Medicare vs. Medicare Advantage Updated

CMS updated the payment rules for patients enrolled in Medicare Advantage Organizations. https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf

April 2024: MLN Educational Tool Medicare Preventive Services Revised

CMS has revised this tool to clarify social determinants of health information, add a link to the most current and comprehensive list of ICD-10 codes for bone mass measurement and colorectal cancer screening, add coding, coverage, and payment information for COVID-19 vaccine and administration, and replace Hepatis B information with a link to the Hepatitis B screening service. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Other Updates

March 26, 2024: GAO Improper Payments: Information on Agencies’ Fiscal Year 2023 Estimates

In this report the Government Accountability Office (GAO) indicates the importance of this information due to the fact that “improper payments – those that should not have been made or were made in the incorrect amount – have consistently been a government-wide issue. Since fiscal year 2003, cumulative improper payment estimated by executive branch agencies have totaled about $2.7 trillion. Reducing improper payments is critical to safeguarding federal funds.” With an estimated $51 billion in estimated improper payments HHC’s Medicare (Medicare Fee-for-Service (Parts A and B), Medicare Advantage (Part C), and Medicare Prescription Drug (Part D)) had the highest estimated improper payments across 14 government agencies.

https://www.gao.gov/assets/d24106927.pdf?emci=4185bdfa-36ed-ee11-aaf0-002248223794&emdi=645794fb-40ed-ee11-aaf0-002248223794&ceid=7931774

March 27, 2024: CMS Releases FY 2025 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1804-P)

CMS is proposing to update payment rates by 2.8 percent. This proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, associated impact analysis, and IRF Quality Reporting Program (QRP). Also included are two requests for information (RFIs) (1) Future Measure Concepts for the IRF QRP, and (2) Creating and IRF QRP Star Rating System.

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1804

CMS Proposed Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/rules-related-files/cms-1804-p

IRF QRP webpage: https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility

March 28, 2024: CMS Issues 3 FY 2025 Proposed Rules: SNF, Inpatient Psych and Hospice

FY 2025 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1802-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-25-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1802-p

FY 2025 Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Quality Reporting (IPFQR) Updates Proposed Rule (CMS-1806-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-medicare-inpatient-psychiatric-facilities-prospective-payment-system-ipf-pps-and

• Of note, CMS has proposed to increase the per treatment amount for electroconvulsive therapy (ECT) from the current FY 2024 payment per treatment of $385.58 to $660.30. CMS believes this increase would help ensure that patients who need ECT are more able to access it. (ECT CPT 90870)

March 28, 2024: OMB Memorandum: Advancing Governance, Innovation, and Risk Management for Agency Use of Artificial Intelligence

This memorandum established new agency requirements and guidance for AI governance, innovation, and risk management, including through specific minimum risk management practices for uses of AI that impact the rights and safety of the public.

https://www.whitehouse.gov/wp-content/uploads/2024/03/M-24-10-Advancing-Governance-Innovation-and-Risk-Management-for-Agency-Use-of-Artificial-Intelligence.pdf

April 1, 2024: CMS Memorandum: Revisions and Clarifications to Hospital Interpretive Guidelines for Informed Consent

In the memorandum summary to State Survey Agency Directors, CMS noted that “based on increasing concerns about the absence of informed patient consent prior to allowing practitioners or supervised medical, advanced practice provider, or other applicable students to perform training- and education-related examinations outside the medically necessary procedure (such as breast, pelvic, prostate, and rectal examinations), particularly on anesthetized patients, we are reinforcing hospitals’ informed consent obligations.” They go on to indicate they are revising the hospital interpretive guidance about informed consent in the State Operations Manual, Appendix A-Hospitals, to address this” concern. https://www.cms.gov/files/document/qso-24-10-hospitals.pdf

Note, on April 19, 2024, CMS published Transmittal 220: Revisions to State Operations Manual (SOM) Appendix A-Hospitals in follow-up to the memo to provide an emphasis on patient informed consent prior to performing sensitive examinations and examinations performed by students for teaching purposes. https://www.cms.gov/files/document/r220soma.pdf

April 1, 2024: Press Release: CMS Finalizes Payment Updates for 2025 Medicare Advantage and Medicare Part D Programs

CMS notes the federal government is projected to pay between $500 and $600 billion in Medicare Advantage payments to private health plans in 2025. CMS also reminds readers that “thanks to the Inflation Reduction Act, President Biden’s lower-cost prescription drug law, annual out-of-pocket costs will be capped at $2,000 for people with Medicare Part D in 2025.” https://www.cms.gov/newsroom/press-releases/cms-finalizes-payment-updates-2025-medicare-advantage-and-medicare-part-d-programs

April 1, 2024: Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f

April 10, 2024: CMS Releases FY 2025 IPPS and LTCH PPS Proposed Rule (CMS-1808-P)

A related fact sheet discusses major provisions of the proposed rule. Be on the lookout for articles about the proposed rule in future editions of the Wednesday@One. https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

April 23, 2024: Progress Toward Advanced Explanation of Benefits (AEOB) Rulemaking and Implementation

CMS posted a five-page document providing progress made to date regarding the No Surprises Act (NSA) to establish new consumer protections from unexpected bills.  https://www.cms.gov/files/document/progress-aeob-rulemaking-implementation.pdf

April Addition to OIG Work Plan: Utilization of Peripheral Vascular Procedures and CMS’s Related Program Integrity Efforts

The OIG notes that in 2022, Medicare paid more than $600 million for atherectomies and angioplasties with and without a stent in peripheral arteries…CMS and whistleblower fraud investigations have identified these surgeries as vulnerable to improper payments. This work will determine trends in Medicare fee-for-service for surgeries in peripheral arteries over several years and identify paid claims that exhibit questionable characteristics. https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000852.asp