12/27/2011
Update - 5010 Transaction Standards

Important Alert – CMS Delays Enforcement Penalties of 5010

The compliance date for use of the new Version 5010 transaction standards remains Sunday, January 1, 2012, however on November 17, CMS’ Office of E-Health Standards and Services (OESS) announced that they would not initiate enforcement action for the use of the new standards until Saturday, March 31, 2012.

Nevertheless, providers are urged to continue preparation for the timely transition to the HIPAA 5010 standards as it is likely that many of your business partners (software vendors, payers, clearinghouses etc.,) will transition to 5010 by the compliance date of January 1, 2012, which would mean those providers who are still using 4010 would experience the rejection of their electronic transactions.  Therefore, it remains vitally important that you complete testing Version 5010 transactions and contact your vendors, payers and clearinghouse to determine when they will be implementing Version 5010.

The enforcement discretionary period is for 90 days after the January 1, 2012 compliance date. According to CMS, if a complaint is received by CMS after January 1, 2012, the entity against which the complaint has been filed will be evaluated to determine its level of compliance. An assessment will be made of the filed-against entity's efforts to test and become compliant. OESS will take appropriate actions as permitted under the authority of the HIPAA enforcement rule, but will not assess any penalties and/or civil monetary penalties during this 90-day period.

10/5/2011
OIG 2012 WORK PLAN

OIG PUBLISHES 2012 WORK PLAN – IDENTIFIES AUDIT & REVIEW ISSUES

The Office of Inspector General's (OlG) 2012 Work Plan is now available on the OIG Website. Each year the OIG publishes the Work Plan, which provides a brief description of audits and reviews they will be initiating or continuing during the fiscal year. Among the review issues listed by the OIG in their 2012 Work Plan are several new reviews that will be of interest to oncologists. The list below is a brief summary of the issue described in the 2012 OIG Work Plan.
  

Physicians and Other Suppliers: High Cumulative Part B Payments (New)
The OIG will review payment systems controls that identify high cumulative Medicare Part B payments to physicians and suppliers. The OIG will determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls. Medicare Part B services must be reasonable and necessary, adequately documented, and provided consistent with Federal regulations. A high cumulative payment is an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse.

Physicians: Incident-To Services (New)
The OIG will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. They will assess CMS’s ability to monitor services billed as “incident-to.”  The OIG states that a previous report found that unqualified non-physicians performed 21% of the services that physicians did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.

Physician-Administered Drugs and Biologicals (New)

The OIG will compare Medicare and Medicaid payments for commonly used physician-administered drugs and biologicals to determine whether changes in the reimbursement methodologies for the Part B drug program would result in significant savings. Medicare Part B pays for most covered drugs and biologicals based on ASP plus 6%. Medicaid also covers physician-administered drugs and biologicals. However, under Medicaid, States have flexibility in determining reimbursement for covered drugs and biologicals as long as the ingredient cost approximates an estimated acquisition cost. In addition, manufacturers must provide rebates for Medicaid-covered drugs.

Medicare Payments for the Drug Herceptin (New)

The OIG will review payments associated with Medicare claims for the drug Herceptin to determine whether they were appropriate. For drug claims involving a single-use vial or package, if a provider must discard the remainder of a single-use vial or package after administering a dose/quantity of the drug or biological, Medicare provides payment for the amount discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label. However, multiuse vials such as those used for supplying Herceptin are not subject to payment for discarded amounts of a drug or biological.

Medicare Outpatient Payments for Drugs (New)

The OIG will review Medicare outpatient payments to providers for certain drugs and the administration of those drugs (e.g., chemotherapy) to determine whether Medicare overpaid providers because of incorrect coding or overbilling of units. Prior OIG reviews have identified certain drugs, particularly chemotherapy drugs, as vulnerable to incorrect coding.

In addition to the new review issues listed above, the OIG will continue to review E/M claims for improper payments. They will review claims to identify trends in coding patterns, and the appropriate use of new or established patient codes, and they will review multiple E/M services for the same providers and beneficiaries, looking for medical records with identical documentation across services, to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

The OIG is also continuing their review of payments for services ordered or referred by excluded providers and payments for off-label anticancer pharmaceuticals and biologicals.  

9/2/2011
Important eRx 2012 Payment Adjustment Changes

CMS FINALIZES eRx PROGRAM CHANGES

On August 31, CMS published the Medicare Program; Changes to the Electronic Prescribing (eRx) Incentive Program Final Rule. In the final rule, CMS finalizes their proposals to modify the eRx quality measure used for certain reporting periods in CY 2011, adopt additional hardship exemption categories for the 2012 eRx payment adjustment, and provide an extension to the deadline for submitting requests for exemptions from the 2012 eRx payment adjustment.

Summary of the significant changes in the final rule:

1. Revises the description of the 2011 eRx measure to indicate that the measure documents whether an eligible professional or group practice has adopted a "qualified" electronic prescribing system, that performs the four functionalities previously discussed, or Certified EHR Technology as defined at 42 CFR 495.4 and 45 CFR 170.102, regardless of whether the Certified EHR Technology has all four of the functionalities previously discussed.
   
   
2. Adds four new significant hardship exemption categories for the 2012 e Rx payment adjustment, bringing the total to 6 significant hardship exemptions:
   
   
   • The eligible professional or group practice practices in a rural area with limited high speed internet access;
   • The eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing;
   • Eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Program and adopt Certified EHR Technology;  New
   • The inability to electronically prescribe due to local, State, or Federal law; New
   • Limited prescribing activity; New
   • Insufficient opportunities to report the eRx measure due to limitations of the measure's denominator. New
     
     
3. Provides an extension of the deadline for submitting requests for exemptions from the 2012 eRx payment adjustment under the additional significant hardship exemption categories, as well as the two significant hardship codes established in the CY 2011 PFS final rule with comment period.
   
   The new deadline for submitting a hardship exemption request is November 1, 2011.
   
   
4. CMS also finalizes the process to request a significant hardship exemption from the 2012 eRx payment adjustment. Individual eligible providers will be required to submit significant hardship exemption requests using a Web-based tool only. CMS states that information on how to access the Web-based tool and detailed instructions for applying for a hardship exemption will be available on the eRx Incentive Program website at www.cms.gov/erxincentive.