A primary care group will settle with the Department of Justice (DOJ) for submitting unsupported diagnoses to the Medicare Advantage (MA) program. Complete Physician Services (CPS) in Philadelphia will pay $1.5M plus interest to settle False Claims Act (FCA) violations for submitting unsupported diagnoses to the MA program.
On May 17, 2023 the Senate Permanent Subcommittee on Investigations (PSI) conducted a hearing looking into denials and delays of care in the Medicare Advantage (MA) program.
Some key points discussed by Senators Blumenthal and Johnson included:
MA beneficiaries facing barriers to access of care and treatment
Delays/denials in medically necessary care
MA plans not offering, at a minimum, the same benefits and coverage criteria as original Medicare
MA plans are using proprietary tools (algorithms and Artificial Intelligence (AI)) to make patient care decisions
There is a need for transparency by MA plans on how they utilize these tools
The three big MA plans (United HealthCare, Humana, and CVS/Aetna) were sent a Senate bipartisan letter on May 17, 2023 asking for internal documents to be provided, which describe how prior authorization decisions were made, to include the utilization of AI tools
Lack of free-market competition in the MA space
The Office for Civil Rights (OCR) announced on April 11, 2023 that providers will have 90-days after the end of the Public Health Emergency (PHE) to become compliant with the HIPAA Rules (HIPAA Privacy, Security and Breach Notification Rules) for telehealth services. Since the beginning of the PHE, the OCR has utilized Enforcement Discretion to determine how violations with privacy, security, and breach notifications would be managed. The PHE ended on May 11, 2023. Providers now have a 90-day transition period (until August 9, 2023) to be compliant with the HIPAA Rules. (Enforcement Discretion for Telehealth Remote Communications During the COVID–19 Nationwide Public Health Emergency – PDF (“Telehealth Notification”), effective from March 17, 2020, to 11:59 pm May 11, 2023.)
HPMS published a memo on May 9, 2023 addressing coverage for over-the-counter (OTC) COVID-19 tests for Medicare Advantage (MA) & Medicare-Medicaid (MMPs) health plans. Typically, Medicare Part B does not cover OTC tests, but with the pandemic, free OTC COVID-19 tests were available to Medicare beneficiaries. With the end of the Public Health Emergency (PHE) on May 11, 2023, free OTC COVID-19 tests will no longer be available.
As of today, the COVID-19 PHE flexibilities issued by the Office of Inspector General (OIG) have come to an end. They “were designed to provide flexibility and minimize burdens for the health care industry as it faced the challenges of the COVID-19 pandemic.”
Read the latest information published by the OIG https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp and previous blogs from The Honest Approach regarding the ending of the PHE.
UNBELIEVABLE! Many times when I see Press Releases from the Department of Justice (DOJ) a couple thoughts go through my head…. “If only they had a better compliance program in place that conducted audits and monitored potential issues, this might not have cost them $XX millions of dollars.” Or, I think … “Wow! That was BOLD!” This is one of those times that I pull out the BOLD thought and add on a “slap my head” emoji!
The Office of Inspector General (OIG) addresses reinstatement to participate in Federal healthcare programs after an individual or entity’s state license has been revoked, suspended or surrendered here: (https://www.oig.hhs.gov/exclusions/reinstatement.asp)
Individuals or entities who have been excluded from participating in Federal healthcare programs can apply to be reinstated upon:
Completion of their defined exclusion period – they can start the application process 90-days before the end of the exclusion period
Regaining licensure that was excluded
Transitional care management (TCM) services are intended to help a patient transition, upon discharge, from an inpatient setting back to their home setting. Here are several areas you will want to look into for proper coding, documentation, and billing guideline use:
Who are the eligible providers that can perform TCM services?
Who can perform the non-face-to-face vs. face-to-face portion of the TCM service?
What types of locations are approved for post-discharge TCM services?
HPMS released a memo with the upcoming deadlines for Medicare Advantage Organizations, etc. to submit their risk adjustment data to calculate risk scores for Payment Years 2022, 2023, 2024, and 2025. Data must be submitted by 8pm on the day of the deadline to be counted in the current run. Submissions after 8pm will be included in the mid-year or final reconciliation run, based on deadline date. See the table below and review the HPMS site for more details.
The Public Health Service Act, initiating the public health emergency (PHE), was declared on January 31, 2020. It has been renewed 13 times since then. The PHE was put into place in response to the COVID-19 pandemic. Several temporary waivers and flexibilities have been implemented by state and federal governments in response to the challenges faced throughout the nation. On January 30, 2023, President Joe Biden announced that the PHE will end on May 11, 2023. The end of the PHE signals the termination of the temporary waivers/flexibilities that were implemented throughout the pandemic (there are a few flexibilities that will extend past May 11, 2023). Healthcare organizations will need to re-examine their current policies, procedures, processes, workflows, etc. in preparation to transition back to “normal” operations.