Medicare

60 Day Final Rule

Effective March 14, 2016, the CMS Final Rule regarding the reporting of overpayments took effect. This ruling clarifies the standards that have been unclear for years since the the PPACA created what is called the "60-day rule." The problem has been the unclear standards on what it means to "identify" an overpayment and when the 60 day clock begins running.

Now, the 60-day rule requires anyone who has received an overpayment from either Medicare or Medicaid to report and return the overpayment within the latter of:

Continuing the commitment to greater data transparency, the Centers for Medicare & Medicare Services (CMS) today released privacy-protected data on the prescription drugs that were paid for under the Medicare Part D Prescription Drug Program in 2014. This is the second release of the data on an annual basis, which shows which prescription drugs were prescribed to Medicare Part D enrollees by physicians and other healthcare professionals.

The scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set are available on the 

CMS has noted that several high volume procedure codes are typically reported with a modifier that unbundles payment for visits from the procedure, even though the modifier should only be used for reporting services beyond those usually provided. Therefore, CMS believes the services may be misvalued. As a result, CMS is proposing to prioritize 83 services for review as potentially misvalued.

 

CMS.gov Fact sheet

The Diabetes Prevention Program is a structured lifestyle intervention that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are pre-diabetic.

Overview

CNN reported an astounding number of individuals charged with false billing. There was about $900 million in false billing that involved Medicare and Medicaid fraud. Along with the $900 in false billing, $36 million in Detroit involved a front for a narcotics diversion scheme. There were 301 defendants charged in the United States involving 61 medical professionals’ 36 Federal Judicial districts and 28 doctors were charged.

Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:

Medicare is implementing a three year Pre-Claim Review Demonstration of Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals and 150 organizations.

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