CMS Updates Manual and Releases MLN Matters Article Regarding Appeals of Claims Decisions – CMS recently issued a Medicare Learning Network (MLN) Matters article in connection with Change Request 11042 released on April 12, 2019 (the Change Request), which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 – Appeals of Claims Decisions). The MLN Matters article is intended for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs).

The MLN Matters article highlights the Change Request’s policy updates and revisions to Publication 100-04, Chapter 29 – Appeals of Claims Decisions, including the following:

  • Section 240.1 (Good Cause) – MACs will document when the MAC finds good cause for late filing on the appeal decision letter or the appeal case file.
  • Section 240.4 (Good Cause – Administrative Relief Following a Disaster) – MACs will observe additional procedures for appeals when a natural or man-made disaster occurs.
  • Section 270.1.2 (How to Make and Revoke an Appointment) – MACs will observe the amendments to accepted forms of signatures, which state that all signatures may be handwritten or electronic, digital, and/or digitized.
  • Section 270.1.6 (Curing a Defective Appointment of Representative) – MACs will observe tolling of an adjudication timeframe when attempting to cure a defective appointment instrument.
  • Section 270.1.7 (Incapacitation or Death of Beneficiary) – MACs will observe enhanced guidance to determine proper parties to appeals and must follow state law when determining proper parties to initial determinations and appeals. Legal representatives of deceased beneficiaries can be proper parties to initial determinations and appeals.
  • The Change Request limits the scope of redetermination review in certain instances, such as redeterminations of “claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor.”
  • The Change Request also adds the terms “Medicare number,” “Medicare beneficiary identifier (MBI),” and “attorney adjudicator” to the glossary and includes “Medicare number” throughout the manual chapter, which incorporates both the Health Insurance Claim Number and the new non-SSN MBI.

The effective date of the Change Request is June 13, 2019. Please click here for the MLN Matters article and here for the Change Request issued to MACs regarding these changes.

New Medicare Policy and Payment Changes Proposed for Inpatient Rehabilitation Facilities – CMS released the Fiscal Year 2020 proposed rule (the Proposed Rule) outlining new Medicare policy and payment changes for inpatient rehabilitation facilities (IRFs) last Wednesday. The Proposed Rule proposes updating IRF payment rates, revising case-mix groups, rebasing the IRF market basket, adding two interoperability measures, and implementing the IRF Quality Reporting Program (QRP). The Proposed Rule is expected to be published in the Federal Register on April 24, 2019, and the deadline to submit comments is June 17, 2019.

New payment rates are proposed for facilities under the IRF Prospective Payment System (PPS). Payments are expected to increase by 2.3 percent (or $195 million) compared to last year using recent data to inform a 2.5 percent increase factor. Outlier payments will stay at 3.0 percent of total payments. If more recent data becomes available, CMS will revise the IRF PPS to reflect that data.

Last year, CMS removed the Functional Independence Measure items from the patient assessment instrument. In the process of finalizing replacement quality indicator data items last year, CMS proposed revising case-mix groups using two years of data. The Proposed Rule implements that proposal by revising the case-mix groups using past data and updating the average length of stay values and relative weights associated with the revised case-mix groups. The Proposed Rule also proposes removing the roll left and roll right from the motor score and applying a weighting methodology to the motor score.

The Proposed Rule also proposes changing the IRF market-basket from a 2012 base year to a 2016 base year. The proposed market-basket is expected to be 3.0 percent and the multi-factor adjustment is expected to be 0.5 percent. The proposed labor-related share is expected to increase 2.1 percent from last year (70.5 percent to 72.6 percent).

Two new interoperability measures will be added to the IRF QRP related to the transfer of health information – a Transfer of Health Information to the Provider Post-Acute Care Measure and a Transfer of Health Information to the Patient Post-Acute Care Measure. The measures are aimed at ensuring that the patient’s medication list is complete and accurate at the time of discharge. In addition, the Proposed Rule proposes adding standardized patient assessment data elements to the IRP-Patient Assessment Instrument. The new elements are intended to improve communication between providers and enhance patient care.

CMS Issues Proposed Rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System – The display copy of the proposed rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) was posted on the Federal Register website last week (the Proposed Rule). The IPF PPS pays psychiatric hospitals, psychiatric units in acute care hospitals and critical access hospitals on a per diem basis for inpatient psychiatric services. The Proposed Rule, which is scheduled to be published in the Federal Register on April 23, 2019, proposes to update the IPF PPS payment rates for FY 2020 based on the most recently available data, and to update the quality reporting program for psychiatric facilities. The deadline to submit comments to the proposed rule is June 17, 2019.

The Proposed Rule proposes to rebase and revise the IPF market basket with data from FY 2016, which will replace the existing market basket that was last updated using FY 2012 data. After applying a 1.25 percent reduction required by statute, CMS estimates that the updated market basket will increase payment rates by 1.85 percent. Estimated payments are further reduced by 0.15 percent to update the threshold amount used in calculating outlier payments. In all, total IPF payments are expected to increase by 1.7 percent in FY 2020 ($75 million).

CMS is also proposing to adopt a new claims-based measure for the IPF quality reporting program. The measure, known as the Medication Continuation Following Inpatient Psychiatric Discharge (National Quality Forum #3205), assesses whether patients admitted to IPFs with diagnoses of Major Depressive Disorder (MDD), schizophrenia, or bipolar disorder filled at least one evidence-based medication within two days prior to discharge or during the 30-day discharge period. CMS is seeking to implement this measure staring with FY 2021 payment determinations.

The display copy of the Proposed Rule is available here.