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Latest Oncology News

SNF SERVICES DENIED IN ERROR TO BE REPROSSED AUTOMATICALLY BY THE MACs

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On March 1, 2018 CMS notified MACs of a Common Working File (CWF) issue causing certain allowable services with dates of service January 1, 2018 through February 27, 2018 to deny incorrectly indicating the service is part of Skilled Nursing Facility (SNF) Consolidated Billing (CB). In some cases overpayment demand letters were issued for claims that were previously paid. The CWF issue was corrected on February 27, 2018. CMS says no provider action is necessary at this time. Affected claims will be reprocessed and recoupment of any money demanded for previously paid claims due to this issue will be halted and/or returned to providers.

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MEDICALLY UNLIKELY EDIT DENIALS REPORTED

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On March 6, Bristol-Myers Squibb announced that the U.S. Food and Drug Administration (FDA) approved a supplemental biologics license application updating the nivolumab (Opdivo®) dosing schedule to include 480 mg infused every four weeks (Q4W). If you are using the new Q4W dosing schedule be aware that HCPCS J9299 nivolumab, 1 mg has a current Medically Unlikely Edit (MUE) value of 440 units. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. MUEs are designed to prevent billing errors by denying items billed above the established number of units. In this case, J9299 would deny for units billed over the established MUE value of 440 (based on previous prescribing information). The MUE files are updated quarterly, in the meantime, MUE denials for J9299 claims of more than 440mgs should…

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Medicare’s 2018 Final Rules

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The first two days of November saw a flurry of activity from the Centers for Medicare & Medicaid Services (CMS) as they released three final rules. On November 1, 2017, CMS issued the 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC). The CY 2018 Medicare Physician Fee Schedule Final Rule was placed on display at the Federal Register on November 2, 2017. This final rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2018. For details of the PFS and OPPS final rules access the Q4 2017 Oplinc Best Practices Newsletter under the Publications tab on this website or go to: http://www.oplinc.com/publications/newsletter-archives/

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CMS Quality Payment Program Updates

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CMS QUALITY PAYMENT PROGRAM The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate (SGR) formula for physician payments and introduced a new Medicare value-based reimbursement system. The new system, the Medicare Quality Payment Program (QPP), has two tracks that providers will choose from, the Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). Providers who are subject to the QPP include physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). Providers that are new to Medicare, and those that meet a low-volume threshold are exempt from MIPS this year as are certain providers participating in an APM. Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an online lookup tool through which providers can determine their participation status in the Merit-based Incentive Payment System (MIPS) by entering their 10-digit National Provider Identifier…

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Fraud and Abuse Initiatives

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In the current political environment, the future of the Affordable Care Act and other health care initiatives is likely to look very different than they do now. However, two initiatives are expected to continue, the movement toward value-based payments, and audits to prevent and recover improper payments. The Q1 2017 Oplinc Best Practices Review Newsletter looks at some of the current health care fraud and abuse programs and discuss what you can do to prepare your practice. Access this newsletter by clicking on Oplinc’s Best Practices Review Newsletter Archive.

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Medicare Updates

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OBAMA ADMINISTRATION HALTS PART B DRUG MODEL On Thursday, December 15, the Obama administration announced that the proposed Medicare Part B Drug Model would not move forward at this time. The decision to halt the program came after much criticism, for the scope and design of the program, from public comments on the proposed rule to a letter signed by more than 170 members of the House to CMS and the Centers for Medicare & Medicaid Innovation (CMMI). In their letter, the congressional members state that CMMI models should be implemented in a voluntary, limited-scale basis, and that the CMMI has exceeded its authority with the development of the mandatory Part B Drug Payment Model. In a statement explaining the decision to halt the proposed program, a CMS spokesperson said, “While CMS was working to address these concerns, the complexity of the issues and the limited time available led to…

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