- LinCare, a home oxygen supplier, was recently fined $29 million for improper billing of Medicare for home oxygen equipment. In the case of equipment like oxygen concentrators, Medicare pays a monthly rental payment to the supplier for 36 months after which the patient gets to keep the equipment at no charge. The oxygen supplier can continue to charge Medicare for supplies like tubing. But, it appears LinCare did not stop billing after three years and continued to collect rental payments from not only Medicare, but also Medicare Advantage (MA) plans.
- UnitedHealth Care (UHC) recently released their coverage guidelines for Leqembi, the new medication for Alzheimer’s. For their MA patients, coverage mirrors the Centers for Medicare and Medicaid Services (CMS) requirements as required by law. But, they also adopted the same requirements for their commercial patients. This is a bit surprising as UHC is free to perform their own efficacy analysis and consider the cost effectiveness of the medication for their commercial patients, a factor that Medicare is not allowed to consider. The only tricky part is that UHC requires the provider prescribing the medication be either a neurologist, geriatric psychiatrist, or geriatrician who specializes in treating dementia. This could certainly serve to limit patient access.
- Last month, CMS released a 400-page proposed rule entitled, “Discrimination on the Basis of Disability in Health and Human Service Programs or Activities.” Your compliance, legal, information technology, and marketing teams are going to be busy with this.
- CMS is proposing to require disabled individuals have access to all electronic services available to others including check in kiosks, web sites, and mobile apps. They specifically mention the Epic electronic health system, noting that if a hospital uses MyChart to allow patients access to their medication lists, test results, and so on, the hospital is responsible for ensuring the same content is accessible to disabled persons.
- CMS also talks about medical equipment and their plans to set specific standards on the type and number each facility must have that are accessible, from beds to x-ray machines to scales.
- While much of this rule talks about physical factors such as these, there is a substantive discussion about the medical care that is and is not provided to patients based on their disabilities. For example, CMS points out that during the COVID-19 pandemic, the SOFA score was often used to measure severity of illness and make clinical decisions. SOFA uses the Glasgow Coma Score which means a patient with a disability like autism would be scored lower because of their inherent difficulty with communication not from COVID-19 infection, but from their known diagnosis of autism which could result in inappropriately withholding care in a care crisis scenario. CMS also discusses the tendency of medical providers to project their own values and perception of quality of life on patients when discussing resuscitation status, referring to cases that were publicized in the media.
- You can read the proposed rule here and comment on it through November 13th.
- As a reminder, a recent Livanta memo discussed the applicability of the case-by-case exception to the two midnight rule using case examples including a patient with gastrointestinal bleeding and one with angioedema. From the descriptions provided, the applicability of the exception to these two cases seemed marginal at best but it was CMS’ statement that any Medicare patient presenting emergently with acute appendicitis or acute cholecystitis who needed surgery could be admitted as inpatient that really raised questions. In both of those cases, the surgery itself is not on the inpatient-only list if done laparoscopically. Of course, that does not mean the patient cannot be admitted as Inpatient if they fit the case-by-case exception or were expected to need two or more midnights, but that is not what Livanta stated. They stated all such patients could be admitted inpatient. But, a few weeks ago, CMS responded via e-mail to our own ACPA Update Editor, Dr. Ronald Hirsch, that they instructed Livanta to retract the memo pending further review. So now we wait for further clarification on the whole issue.
- There has been a lot of chatter about the applicability of the Two-Midnight Rule to MA plans. The final rule that formally obligated the MA plans was finalized in April of this year with the rule stating that the regulations are effective June 5th. But, none of the MA plans changed one thing on June 5th, which might very well be justified since the next line in the CMS rule states, “the provisions in this rule are applicable to coverage beginning January 1, 2024.” This actually makes sense because each year, MA plans submit bids to CMS to get contracts to be a Part C entity. For the current calendar year, the MA plans are paid based on their bids submitted back in 2022. In 2022, their expectation was that in 2023, they would be able to continue to fail to abide by the Two-Midnight Rule as they have done up to this point, with CMS’ permission, since 2013. Requiring the plans to start following the Two-Midnight Rule in the middle of 2023 would not be fair to the MA plans as there would be significantly more inpatient claims to pay and that would endanger their profits. Passage of the rule in April with applicability in 2024 allows MA plans to appropriately adjust their 2024 bids that were due this June to compensate for the cost of all the anticipated new Inpatient claims.
**Content compiled and summarized by Juliet B. Ugarte Hopkins, MD. The news above in addition to many other points of interest for physician advisors and other leaders in healthcare can be heard weekly during Dr. Ronald Hirsch's Monday Rounds segment on RACmonitor.com's Monitor Mondays webcast/podcast. Learn More.
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