IN THIS WEEK’S ISSUE:
- CMS Describes Dual Eligibles’ Transition to Medicare Part D
- Dual Applications Dropped for Section 1011 Enrollment; Payment Request Deadline Extended
- OIG Notifies Miami Hospital of Pending Exclusion for Breaching CIA
- NPI Transition Period Clarified for Revised 1500 Form
- Electronic Filing Waivers Possible in Limited Situations
- Medicare Proposes Bariatric Surgery Coverage
- New Requirements Issued for Lung Volume Reduction Surgery
- GAO Evaluates CMS Management of the IT Investment Process
- IRS Issues 2006 Standard Mileage Rates
- Quick Links
- New in the Resource Center
1. CMS DESCRIBES DUAL ELIGIBLES’ TRANSITION TO MEDICARE PART D
The road to a safe and appropriate transition of the dual-eligible population from Medicaid to Medicare Part D prescription drug coverage starting January 1 has been adequately mapped, CMS asserts in a fact sheet released December 1. The transition plan strives to ensure the continuity of coverage and care for the dual eligibles, who often take a number of prescription drugs to manage chronic conditions.
Major elements of the transition include: exceptions procedures designed to ensure that enrollees receive prompt decisions regarding whether medications are medically necessary; specific protections for beneficiaries who live in long-term care facilities; auto-enrollment to ensure that there is no lapse in prescription drug coverage for full dual-eligibles; focused assistance for dual-eligibles; collaboration with states to ensure the needs of their current dual-eligible residents are met and that there is a successful transition of new dual-eligible individuals; and a process for a point-of-sale solution to ensure full dual-eligible individuals experience no coverage gap when Part D coverage starts.
2. DUAL APPLICATIONS DROPPED FOR SECTION 1011 ENROLLMENTS; PAYMENT REQUEST DEADLINE EXTENDED
Effective December 1, 2005, providers are no longer required to submit both a hard copy and an electronic Section 1011 enrollment application,announced TrailBlazer, the claims processor and payer for Medicare Modernization Act Section 1011, which covers certain unreimbursed healthcare costs for undocumented aliens. To simplify the enrollment process, only signed, hard copy enrollment applications will be required and accepted. TrailBlazer will continue to process electronic enrollment applications received to date if a matching hard copy application is also in-house.
Trailblazer also announced that the deadline for providers to file their payment requests has been extended 180 days from the end of the federal fiscal quarter in which to file their payment requests, because providers did not have the full billing period for this first quarter. The filing deadline for third-quarter FY05 payment request submissions is now January 11, 2005, rather than December 27, 2005.
3. OIG NOTIFIES MIAMI HOSPITAL OF PENDING EXCLUSION FOR BREACHING CIA
The HHS OIG announced Wednesday that it has notified Miami’s South Shore Hospital and Medical Center (South Shore) that the agency has proposed excluding the hospital from Medicare, Medicaid and all other federal healthcare programs. The OIG’s action is based on a breach of the terms in the corporate integrity agreement (CIA) that the Florida hospital negotiated with the OIG in 2002 that was part of the resolution of a False Claims Act case against the hospital.
The OIG reported that South Shore continually failed to submit complete, accurate, and timely implementation and annual reports and failed to implement all of the independent review organization requirements of the CIA, which called for specific types of cost reporting reviews and engagement procedures. South Shore also failed to notify OIG, as required, of its sale to new owners, who are also subject to the terms of the CIA. South Shore has 30 days to demonstrate that it is in compliance with the agreement, that it has cured the breach, or that it is in the process of doing so with due diligence.
4. NPI TRANSITION PERIOD CLARIFIED FOR REVISED 1500 FORM
CMS has provided clarification of the transition period for the revised CMS-1500 form (which ends February 1, 2007) and effectively served up a reminder of the need to apply for a national provider identifier (NPI). Revised Medlearn Matters article MM4023, describes CMS’s plans for transitioning to the NPI in the fee-for-service Medicare program. Providers should note that beginning January 3, 2006, CMS’s claims processing systems will accept claims with an NPI, but an existing legacy Medicare number must also be on the claim. Any claim that includes only an NPI will be rejected as unprocessable.
Providers have had since May 23 to apply for the NPI.
5. electronic filing waivers POSSIBLE IN LIMITED SITUATIONS
The IRS has issued a notice establishing the bases under which tax-exempt organizations can request waivers from the electronic filing requirement, as well as providing instructions on making the request. Waivers are possible for:
- Organizations that cannot meet electronic filing requirements due to technology constraints; or,
Where compliance with the requirements would result in undue financial burden
The e-filing requirement is being introduced in phases. For tax year 2005 returns that are due in 2006, affected corporations and tax-exempt organizations are those with assets of $100 million or more that file 250 or more returns a year, including income tax, excise tax, information, and employment tax returns. For tax year 2006 returns due in 2007, affected organizations are those with $50 million or more in assets that file 250 or more returns a year.
6. MEDICARE PROPOSES BARIATRIC SURGERY COVERAGE
In an effort to reduce health risks associated with obesity, CMS has proposed a new coverage policy for bariatric surgery procedures. Under the proposed coverage decision, Medicare will pay for laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding for Medicare beneficiaries under the age 65. To qualify for coverage, a facility must meet evidence-based standards for bariatric surgery. Seniors aged 65 and older are not covered under this policy based in part on recent evidence that shows elevated risks in older beneficiaries, CMS said.
CMS also proposes facility criteria for the covered procedure, including credentialing for surgeons, a review of staff and consultant qualifications, an integrated program for patient care, written procedures for patient consent and adverse event reporting, and appropriate equipment for patient care. In addition, the agency seeks comment on whether to expand the facility criteria to include specific bariatric surgery volume criteria for surgeons or facilities.
7. NEW REQUIREMENTS ISSUED FOR LUNG VOLUME REDUCTION SURGERY
In a December 2 transmittal, CMS published changes to the requirements for facilities eligible to perform lung volume reduction surgery (LVRS). For services furnished beginning November 17, 2005, LVRS is reasonable and necessary when performed in facilities that are:
- Certified by the Joint Commission on Accreditation of Healthcare Organizations under the LVRS Disease Specific Care Certification Program;
- Approved as Medicare lung or heart-lung transplantation hospitals; and
- Approved by the National Heart Lung and Blood Institute to participate in the National Emphysema Treatment Trial for LVRSs performed between January 1, 2004, and May 17, 2007.
The transmittal, number 44, is effective November 17, 2005.
8. GAO EVALUATES CMS MANAGEMENT OF THE IT INVESTMENT PROCESS
CMS’s capabilities for effectively managing its internal investments are limited, and CMS should have been able to manage its FY05 information technology (IT) funding more effectively, the Government Accountability Office (GAO) has concluded. This assessment is based on the GAO’s structure for IT investment management that measures the maturity of an organization’s investment management process. In FY05, CMS’s total IT appropriation was about $2.55 billion, of which about $760 million, or 30 percent, was to support internal investments.
Specifically, the GAO reports that CMS has established a little more than half of the foundational practices it needs to manage individual investments and has executed two of the 27 key practices needed to manage investments as a portfolio. The GAO says that until CMS fully establishes more business and portfolio-level practices, executives will lack the assurance that they are managing the agency’s collection of investments in a manner that minimizes risks and maximizes returns. While CMS has initiated steps to improve its investment management process, these steps do not fully address the weaknesses GAO identified, according to the report.
9. IRS ISSUES 2006 Standard Mileage Rates
The IRS has published the 2006 optional standard mileage rates used to calculate the deductible costs of operating an automobile for business, charitable, medical, or moving purposes. Beginning January 1, 2006, the standard mileage rates for the use of a car (including vans, pickups, and panel trucks) will be:
- 44.5 cents per mile for business miles driven;
- 18 cents per mile driven for medical or moving purposes; and
- 14 cents per mile driven in the service of charitable organizations other than activities related to Hurricane Katrina relief.
For 2006, Katrina-related charitable rates will be 32 cents per mile for deduction purposes and 44.5 cents per mile for reimbursement purposes.
For the first eight months of 2005, the rate for business miles was 40.5 cents. In September, the rate rose to 48.5 cents per mile in response to the sharp increase in gas prices, which topped $3 a gallon.
10. QUICK LINKS
UPDATED ICD-9-CM GUIDELINES. CMS and the National Center for Health Statistics have released updated guidelines, effective December 1, for identifying the diagnoses and procedures that must be reported when billing for medical services using the ICD-9-CM.
2006 DME FEE SCHEDULE UPDATE. Under the new 2006 fee schedule update for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), modifiers AV and AU are being added to HCPCS code A5120 for items furnished in conjunction with facial prosthetics and urological supplies. (Note: you may get an error when trying to access this page, because of the CMS site update activities.)
CMS Web Site Redesign PREVIEW. CMS has been redesigning its web site this month, a process that has made some information inaccessible, but that is due to end on December 15. Users can view an on-line preview of the new site’s look and features (requires Flash).
OIG’S SEMIANNUAL REPORT TO CONGRESS. Accountability for Medicaid funds and payment for Medicaid prescription drugs were the focal points of the OIG’s work during the six-month period ending September 30, 2005, according to the agency’s semiannual report. One of the OIG’s biggest challenges was preparing for the implementation of Medicare Part D.
MEDICAL ASSISTANCE PERCENTAGES. The FY07 federal medical assistance percentages and enhanced federal medical assistance percentages were published in the November 30 Federal Register. They are used to determine the amount of federal matching funds for medical services under Medicaid and state children’s health insurance programs.
11. NEW IN THE RESOURCE CENTER
CY06 OUTPATIENT PPS FINAL RULE READY-TO-USE PRESENTATION. Use this presentation to brief staff and board members on the highlights of the outpatient PPS update.
Copyright 2005 Healthcare Financial Management Association, all rights reserved. HFMA Express News ISSN: 1540-0689. Volume 12, Number 48. Editor: Rob Fromberg, rfromberg@hfma.org, (800) 252-HFMA, ext. 385.
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