http://optimalsolutionsgroup.com/CMS/index.html

Questions can be answered by the CMS contractor:

EMAIL:  maqro@optimalsolutionsgroup.com
PHONE: 866-962-6826

 CMS has extended the data submission deadline to Aug 27, 2010.  This is a compliance requirement so make sure your plan has a program to collect and report this information to CMS.

Part C reporting is a compliance requirement and plans that fail to submit data on time and in good fail will receive a compliance letter and notification.

 The updated specification memo can be retrieved from the CMS web site at this location:
http://www.cms.gov/HealthPlansGenInfo/Downloads/PtCReptTecSpecsFinal_06.03.10.pdf

AISHealth

CMS said recently that hospitals can’t charge Medicare for more than one IV push injection of the same drug during the same patient encounter (HCPCS code C8952C), according to new guidance on billing for drug administration under the outpatient prospective payment system (OPPS). Only multiple injections of different drugs can be charged separately, according to the guidance, which comes in the form of answers to frequently asked questions (FAQs) and was posted on the CMS Web site in mid-February.

This is the latest in a series of OPPS drug administration changes to cause revenue and/or compliance challenges for hospitals.

Here are the highlights of the Deficit Reduction Act signed in to law on February 8, 2006:

• Fee for Services payments to physicians will NOT be reduced by 4.4%. Claims that have been already processed will be reprocessed. Retro payments will be paid through July 1, 2006.
• Increase in the base payments to ESRD facilities for 2006. Claims that have already been paid will be reprocessed.
• Hold harmless payments for rural hospitals will be reinstated.
• 5% add-on payment to rural home health services to rural beneficiaries
• Caps to outpatient therapy services went in to effect Jan 1 2006. $1,740 per beneficiary per year for speech and occupational therapy.
• Changes to rental arrangement for DME equipment. “Capped rental” equipment are rented by Medicare for 13 months (was 15 months) and the title now transfers to the beneficiary after the 13 month period. The title use to rename in the name of the DME rental company.
• Oxygen equipment is now rented for 36 months (was indefinitely) and the title transfers to the beneficiary at the expiration.
• The minimum number of days that a non-electronic claim will be paid changed from 27 to 29 day

COMPLETE MEMO FROM CMS

“Part D plans should not be requiring a Part B rejection as their first step before they’ll start thinking about covering it under Part D,” Craig Miner, a pharmacist with CMS’s Division of Drug Plan Policy, told call participants. “In other words, they need to take further steps to see if there is reason to believe that it should be Part B [which covers outpatient medical expenses], and in that case, perhaps, they can get to the situation where it makes sense for them to say, ‘we’re not going to cover it under D unless there’s a Part B rejection,’” he said.

CMS will not reimburse for drugs that can be covered under Part B if they are billed as Part D. According to call participants, as a result, many plan sponsors are refusing to cover injectable and infusible drugs unless a Part B rejection is presented first.

Miner acknowledged that in some cases whether to request a Part B rejection is clearly a judgment call, and that CMS does not provide specifics on the issue. Instead, “I would say…what we would expect in general is that plans would have policies and procedures…[at] the level that is appropriate and necessary…to make B vs. D determinations,” he said. “It doesn’t have to be a one size fits all.”

CMS officials emphasized that Part B coverage has not changed, so that drugs previously covered under Part B — including immunosuppressants for patients who received transplants at a Medicare-approved facility, oral oncology agents used for cancer indications, and erythropoietin for treatment of anemia in dialysis patients — remain under Part B. CMS staff also clarified that inhalation drugs dispensed through machines in nursing homes, as well as diluents used for mixing drugs (but not saline and other flushes) are indeed covered under Part D.

One area of controversy surrounding CMS’s Part B vs. Part D policy is reimbursement for home infusion (HI) drugs. Under Part D, although the drugs themselves are covered, the related supplies, equipment and support services are not, creating billing problems, coverage gaps and confusion for plan sponsors, HI providers and patients. The National Home Infusion Association and its members are calling for HI drugs to be shifted to coverage under Part B.

A few Medicare Advantage prescription drug plans (MA-PDs) have crafted their own solution to the Part D HI problem, but it is not yet clear whether their policy will withstand CMS scrutiny. According to NHIA, at least two managed care organizations — Blue Cross Blue Shield of Massachusetts and Horizon Blue Cross Blue Shield of New Jersey — have made the decision to continue covering HI for their MA-PD patients as a medical benefit, instead of split-billing drugs and services.

View CMS’s Part B vs. D coverage guidelines at www.cms.hhs.gov/Pharmacy/ Downloads/partsbdcoverageissues.pdf.

Excerpts from AISHEALTH News of the Week

Implementation of the National Provider Identifier(NPI) is moving forward. We should stay on top of the current implementation calendar and recent CMS guidance.

Here is a link to the CMS site where there is a letter clarifying CMSs expectations on determining subparts to covered entities who should bill CMS using unique NPIs. Here is an excerpt clairfying how organizations should define subparts:

Generally, the type of service being reported on a Medicare claim determines the type of Medicare contractor who processes the claim. Medicare will expect an enrolled organization health care provider or subpart to use a single (the same) NPI when billing more than one type (fiscal intermediary, carrier, RHHI, DMERC) of Medicare contractor. However, in certain situations, Medicare requires that the organization health care provider (or possibly even a subpart) enroll in Medicare as more than one type of provider. For example, an ambulatory surgical center enrolls in Medicare as a Certified Supplier and bills a carrier. If the ambulatory surgical center also sells durable medical equipment, it must also enroll in Medicare as a Supplier of DME and bill a DMERC. This ambulatory surgical center would obtain a single NPI and use it to bill the fiscal intermediary and the DMERC. Medicare expects that this ambulatory surgical center would report two different Taxonomies when it applies for its NPI: (1) that of Ambulatory Health Care Facility—Clinic/Center–Ambulatory Surgical (261QA1903X) and (2) that of Suppliers—Durable Medical Equipment & Medical Supplies (332B00000X) or the appropriate sub-specialization under the 332B00000X specialization.

P4P is already on its way and most organizations that manage Medicare lines of businesses are not preparing for the changes in data collection and reporting. Here is a good article outlining the P4P programs already in demonstration with CMS and where they are headed. Now is the time for us to pay attention and begin planning and preparing.

The goal of this broadcast is to provide Health Plans, Employers, Unions, and Part D Sponsors and potential applicants with an update on changes and/or revisions on the following topics:

• Overview of the Medicare Advantage Application requirements and process for the 2007 contract year for Coordinated Care Plans (CCP), Private Fee For Service (PFFS), Service Area Expansions (SAE) and Medical Savings Account (MSA)
• Overview on the Part D application process for the 2007 contract year
• New Part D sponsors seeking to offer a prescription drug benefit and existing Part D sponsors seeking to expand current service areas.
• Benefit design, enrollment, and pharmacy access requirements
• Special Needs Plans (SNP)
• Applications for employer and union direct contracts

Target Audience
New and existing health plans, employers, unions, Part D sponsors and other interested parties

Registration and Viewing Instructions
Information on registration and viewing instructions for the Satellite broadcast and Webcast will be posted under “Announcements” at (cms.hhs.gov/MedicareAdvPartDTrain) by January 20.

Webcast Information
This broadcast will have a live Webcast in conjunction with the Satellite transmission. The broadcast will also be archived for one month. Instructions on how to view the Webcast will be forthcoming. If you have questions regarding viewing and registration for this program, please contact Du’Va Clyburn at (410) 786-2161.

Guidance for Locating Downlink Sites
In general, there are 2 major formats for satellite transmission – digital and analog. CMS uses both analog and digital formats, CMS’s Digital network is a closed network which can only be viewed by its ten regional offices and several State survey agencies in regions VIII, IX, and X. The Digital format that CMS uses is called Digicipher. CMS is also capable of transmitting and receiving programs in KU-band and C-band analog. Ku-band and C-band have been in use for many years, can be received by thousands of ‘steerable’ analog dishes nationwide. C-band is the oldest transmission signal and the most widely used. NOTE: This is NOT ‘video conferencing,’ which is carried by telephone lines.

Locating an Analog Downlink Site
Potential Analog Downlink Sites: There are thousands of steerable analog downlink dishes nationwide at public schools, colleges, libraries, hotels, television stations, restaurants, private residences, etc. A few calls should locate one near you.

Here are some places to start calling:
Your Local Cable and Satellite Television Provider: Contact your local cable/satellite television distributor, which is probably listed under “Television — Cable & Satellite.” Ask to speak with the programming staff and inquire about their willingness to simulcast the broadcast on your area’s public access channel. Advise them that this broadcast is free of charge. Satellite television distributors may be able to provide you with a list of public institutions such as libraries, community centers, health care centers, and public schools that subscribe to their services. You may also wish to contact your local public TV station and ask that they download and air the program on their station.

Public Libraries: Larger public libraries are a good place to check for satellite downlink facilities. Check library listings in the local government section of the blue pages of your local telephone directory.

Educational Institutions: Universities, community colleges, and large public high schools often have satellite downlink capabilities.

Hotels and Business Centers: Large hotels that frequently host conventions in business districts, may be able to receive satellite broadcasts. These hotels may charge a fee for viewing.

Health Care Facilities: Many hospitals and health maintenance organization (HMO)

offices have satellite reception capabilities.

Copy Centers: Commercial office supply centers may also have satellite capabilities.

What Information Do I Need to Give the Site Contact Person?

When you contact an analog site, you will need to give the contact person the satellite coordinate information. The coordinates for the broadcast should be made available from the Central Office contact approximately 30 days prior to the broadcast.

Here is the information you will need to provide:

Transmission Type:
Satellite:
Orbital Location:
Transponder:
Polarity:
Downlink Frequency:
Satellite Help Hotline:
Broadcast Schedule:
Test Signal:
Broadcast Title:

Reserving a Downlink Site

You will need to know what to ask the person who answers the phone, who may or may not be the best person at that organization to help.

If the facility has an analog satellite:

You are interested in viewing a satellite C-band and/or KU band analog broadcast and you understand that this facility may have that capability. You should have the satellite coordinates for reference. Some satellite dishes can’t be pointed to all satellites.

You should also ask:

If the facility can receive the broadcast, is the viewing room open to the public and not reserved for another use at the time of the broadcast?

If the viewing room is available, how many people will it hold, and is there any fee for its use?

Will the facility let you phone or fax your questions in to a toll free number?

You should point out that this broadcast is open to the public and employees of the hosting facility with an interest in the topic are welcome.

As a courtesy, you should offer the hosting facility a list of the people who will attend.

Are there any special arrangements necessary for entry to the site?

It is your responsibility to arrange for sign language interpretation if you anticipate that individuals with hearing impairments will attend.

If you find a site, you should be prepared to perform as site coordinator.

Typically, site coordinators will:

Locate a suitable location.

Promote the event locally.

Direct individuals to register if necessary

Download material (e.g., sign-in sheet, evaluation, participant guide) if available

Ensure that participants sign in on the day of the event.

Distribute copies of the participant guide and handouts to participants the day of the broadcast.

Assist participants with the use of the distance learning equipment.

Receive instructions from the broadcast director regarding any activities they may be asked to facilitate.

Encourage active participation in event activities.

Record the broadcast for office use.

Encourage participants to complete the evaluation form (included in the handout).

Mail/fax the sign-in sheet and completed evaluation form to Central Office following the event.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires entities that provide prescription drug coverage to Medicare Part D eligible individuals to disclose to CMS whether the coverage is creditable or non-creditable. CMS has issued guidance on the form, manner and timing of providing the Disclosure Notice to CMS. This Disclosure to CMS guidance is posted on the Creditable Coverage web page at http://www.cms.hhs.gov/CreditableCoverage/.

An entity is required to provide the Disclosure Notice through completion of the Disclosure Notice form on the CMS Creditable Coverage Disclosure Web Page at http://www.cms.hhs.gov/apps/ccdisclosure/default.asp unless specifically exempt as outlined in the Disclosure to CMS guidance. Additional information about creditable coverage is available on CMS’ Creditable Coverage web page at http://www.cms.hhs.gov/CreditableCoverage/.