Knowledge Base Article

Did you know that Section 6401 of the Affordable Care Act (ACA) provides that a “provider of medical or other items or services or supplier within a particular industry sector or category” shall establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)? Although an enforcement date has yet to be issued, the Secretary of Health and Human Services (HHS), in consultation with the HHS Office of Inspector General (OIG) have established seven core or key elements of an effective compliance program as required by the ACA.

The 5th core element is Auditing and Monitoring. CMS indicated in an Affordable Care Act Provider Compliance Programs: Getting Started Webinar that “a system for auditing and monitoring must be implemented to measure the effectiveness of the compliance program, ensure compliance with CMS requirements, and identify compliance risks.”

Ensuring compliance with CMS requirements is a full time job in and of itself and we recognize that our clients are busier than ever. As Making HealthCare Make Sense is what we are about, we have added a standing article the last week of each month spotlighting key Medicare Transmittals released by CMS during the month.

January 2016 Transmittals

January 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.0

• Numbers: Transmittal R3437CP, Change Request 9459, MLN Matters MM9459
• Dates: Issued: 01/06/2016, MLN: 1/11/2016, Implementation: 1/4/2016
• Affects: Providers who submit claims to Medicare Administrative Contractors, including Home Health and Hospice MACs (HH+H MACs) for services provided to Medicare beneficiaries
• Updates: Medicare Claims Processing Manual, Chapter 4, Section 40.1

Summary of Changes: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the OPPS and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -2nd Qtr Notification for FY 2016

• Numbers: Transmittal R258FM, Change Request 9532, MLN not released at time of this article
• Dates: Issued: 01/12/2016, Implementation 01/19/2016
• Affects: Medicare Providers
• Updates: Medicare Financial Management Manual, Chapter 3, Section 10

Summary of Changes: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. Treasury utilized the most comprehensive data available on consumer interest rates to determine the certified rate. Interest is assessed on delinquent debts in order to protect the Medicare Trust Funds.

Award of Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Contract for Jurisdiction D

• Numbers: Transmittal R1592OTN, Change Request 9453, MLN not released at time of this article
• Dates: Issued: 01/15/2016, Implementation: 03/01/2016
• Affects: Providers submitting DME claims for Medicare beneficiaries inJurisdiction D (U.S. Territories of Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, and Norther Mariana Islands.
• Summary of Changes: The purpose of this change request is to announce the award of the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Jurisdiction D contract to Noridian Healthcare Solutions, LLC for the administration of Medicare DME Fee-for-Service (FFS) claims.