News to Note – July 2020

• Things are starting to get back to normal with the Medicare Advantage (MA) plans once again denying inpatient admissions. Equiclaim, a contractor for UnitedHealthcare (UHC), is also downgrading DRGs that UHC themselves already audited and approved. And, a big question is – what will be the new normal for telehealth? Seema Verma hinted that some of the temporary changes may be made permanent but which and when is unknown.
• What’s happening with telehealth is not all good. The Centers for Medicare and Medicaid Services (CMS) just finalized a rule that includes an expansion to telehealth rules for MA plans. As a background, for an MA plan to be sold in an area, they must have an adequate network of contracted physicians and facilities to take care of the patients who enroll. The new rule allows MA plans to count doctors who are contracted and can provide services via telehealth in eight specialties – Ophthalmology, Allergy, Nephrology, Primary Care, Gynecology, Endocrinology, and Infectious Diseases. Think about that for a moment: A patient with glaucoma and diabetes signs up with an MA plan after being told the plan has contracts with all the doctors they will need. It’s not their usual doctors, but the lure of a free health club membership was too good to pass up. Well, it ends up the contracted doctors are actually 100 miles away but are available by telehealth. So, now the patient has to drive 100 miles to get their eye pressure checked. What about a Medicare patient who needs to see a gynecologist for vaginal bleeding but that doctor is on the other side of the state? How well can a telehealth examination evaluate the cause of that? Once again, the move by CMS to increase MA enrollment and profits reinforces the opinion some have that MA plans are great until you actually need medical care. 
• Both the Lancet and the New England Journal of Medicine, two of the most respected medical journals in the world, had to retract publications related to COVID-19. One paper had findings so significant that its publication led to many organizations stopping their trials of hydroxychloroquine as a treatment. Both papers were written using patient data from the same organization, Surgisphere. But, as people started reviewing the results, the legitimacy of the data was called into question and Surgisphere refused to provide the source data. Fortunately, other trial data is available that did confirm that hydroxychloroquine actually was ineffective so there was no lasting damage from that. For some this fiasco calls into question our whole process of accumulating new medical knowledge. 
• The staff at CMS has done a wonderful job with the waivers and regulation changes related to billing Medicare for services during the COVID-19 pandemic in such a short period of time. One of the sticking points for hospitals that owned physician practices was how to properly bill for telehealth visits by their doctors. In normal times, there is a physician professional fee and a facility fee. But, with telehealth the patient does not come to the facility. So, CMS said that the hospital could designate the patient’s home as a provider based clinic and bill an originating site fee for the visit. This pays substantially less than a facility fee but at least it brought payment parity compared to independent doctors. But, on the CMS call the first week of June, suddenly the CMS representative said facilities can bill the facility fee. What? This is not written anywhere by CMS, so it is real? We don’t know. CMS also did something similar with therapy services provided remotely by hospital employees. For weeks and weeks CMS said that hospitals can bill for this by designating the patient’s home as a provider-based clinic but that it is not telehealth, it is remote provision of services. Then, all of a sudden on May 27th, CMS released an FAQ that says these services can be provided and billed via telehealth. Many are getting to the point of recommending people just bill whatever service was provided however one desires and it will get paid as that may be the new CMS philosophy. We shall see how things pan out. 
• At the end of June, a MAC made a huge mistake in a webinar on physician billing for COVID-19 services. They said if a physician orders a chest x-ray, the radiologist should put the CS modifier on their claim for reading the x-ray and Medicare will pay 100%. After ACPA Advisory Board member, Dr. Ronald Hirsch screamed at his computer, he replied with a citation from the law that says the CS modifier only goes on evaluation and management services claims. They disagreed with him and insisted all outpatient services from physicians could get the CS modifier. Of course, CMS agreed with Dr. Hirsch. 
• The COVID-19 pandemic did not change the timeline for the Medicare outpatient prior authorization program for selected surgeries. Some things to note: 1) Of course it is nationwide and mandatory. But, for some strange reason this only applies to hospital outpatient surgeries and not to the same procedures done in an ambulatory surgery center or a doctor’s office. 2) The new regulation says that submitting a prior authorization request is now a condition of payment. No prior authorization means no payment. But, what happens to a claim that is submitted without a prior authorization? It will be denied, of course. And, then what happens? The provider gets appeal rights. That means they can send in the medical records and if medical necessity is met, payment is made. So, prior authorization is required but it is not required? It certainly makes sense to get the prior authorization and you certainly will be paid faster, but know you have options if one slips through the cracks. 
• July 1st was the day five procedure classes started to need prior authorization: blepharoplasty, botox injections in the face, panniculectomy, rhinoplasty, and vein ablation. 
• It’s only for outpatient procedures done in hospital outpatient departments, ASCs were not saddled with the requirement. 
• The MACs have 10 business days to review the documentation and provide a response. Once they review it they will either give a thumbs up or thumbs down. In usual CMS fashion, they won’t call that an approval, they will call it an affirmation. Why is that? Because if they give an approval, then they have to pay it. But, if they call it an affirmation, then they still have the ability to audit the claims retroactively and deny them. 
• CMS claims that these procedures will not be routinely selected for audit but they will be watching data and can selectively audit. It is the hospital’s responsibility to obtain the prior authorization but they won’t be able to accomplish it unless the doctor provides the medical records. If hospitals are smart, they won’t let doctors’ offices schedule the procedure unless the prior authorization has been completed. But, just in case you have one of “those doctors,” CMS has confirmed that if there is no affirmation for the procedure, the hospital won’t get paid and any associated physician claims will also be denied. And, if the physician claim gets denied, they have to appeal themselves. The hospital can’t do it for them. You can be sure anesthesiologists will not be happy if they don’t get paid because the surgeon would not provide medical records to the hospital. 
• Does this program make sense? CMS has said that it will cost them $7.4 million to administer the program to review the 120,000 procedures that are performed each year with payments of $115,000,000. That means that at least 6.5% of all requests must be denied for Medicare to save money. That’s a pretty high hurdle. 
• Another wonky aspect of the program is this: It’s a nationwide program but it relies on the local decisions of the MACs. If you put their medical necessity standards next to each other, there are significant differences. Take panniculectomy: This is commonly performed after bariatric surgery when patients lose significant weight. Palmetto will not approve panniculectomy unless 18 months have passed since the bariatric surgery. But, Novitas won’t approve it until 24 months have passed. Novitas also requires the BMI to be less than 35 – a requirement not in their own LCD, they just made it up and stuck it on their web page. So, if your system covers multiple MACs, you better check each MAC’s requirements, carefully. 
• Unfortunately, the run-up to July 1st and the prior authorization requirement included many missteps by some of the MACs. They were supposed to start accepting requests on 6/17. But, even after that date, one MAC’s webpage on the program had no information on how to submit a request until many days later. Additionally, there was no address, fax number, nor mention about their electronic portal. The CMS operational manual has the address and fax number, but the operational manual is not where a hospital should have to go look. And, one hospital in this MAC’s jurisdiction was told the online portal was not even working, so they could not accept requests. 
• Another MAC seemingly got everything up and running, posting links their forms on their web page in time. But, in the form listing, it stated “botulism prior authorization.” Patients don’t need to get prior authorization to get botulism, they need prior authorization to get injections of botulinum toxin. Later, the form was changed to “botulism toxin.” This MAC’s forms are also strange. For instance, their panniculectomy form has a question about if the patient has had bariatric surgery and either has a BMI under 30 or has lost 14 BMI points. Where did that come from? It appears they literally just made up criteria. 
• Speaking of forms, CMS made it clear that the MACs cannot require the use of forms. As long as you send the required information, they have 10 days to review it. But, one MAC told a hospital that if they don’t use their forms, their requests might get routed incorrectly and not done in time. Yikes. 
• At the end of June, NGS had a webinar on the program and they made mistakes. First, they said that the physician office is not permitted to obtain the prior authorization, which is wrong. CMS does not care if it is the hospital or the physician office that submits the request as long as all the information is present and the authorization number gets on the hospital claim. It may be that the physician cannot access the NGS online submission system, but using that is not a requirement. Second, they kept saying that related claims such as the physician claims may also be denied. That’s not what CMS says. CMS says that related claims will be denied. There is a big difference between “may be denied” and “will be denied” and none of us want to tell doctors they won’t get paid only to have their claims get processed and paid with no recoupment. NGS did provide one useful bit of information: RNs will be reviewing the requests with their medical directors providing assistance. Good to know that unlike the RACs, they will not be using physical therapists to review medical necessity for surgery. 
• Hospitals can test out of this program if they get a 90% affirmation rate after six months. What is not known is how they will calculate this. If you submit a request and the initial request is not affirmed because the doctor forgot to document prior treatments and you submit that information later and get the request affirmed, is that considered a 50% affirmation rate or a 100% affirmation rate? That makes a big difference but we are not sure, as of yet. 
• If any of these procedures are performed and an Advanced Beneficiary Notice (ABN) is used to shift liability to the patient, every claim will be held and a copy of the ABN requested and reviewed to ensure it was the right form and that it was completed correctly. If there are any errors or the wrong form is used, you can’t make the patient pay. 
• Speaking of the ABN, a new one was just released by CMS. The content is exactly the same as the old form but the expiration date has changed. CMS is giving providers until August 31st to start using the new form. If you want to find the new form, just google “CMS ABN form” and it should be the first result. 
• CMS announced a new program with a press release entitled, “CMS Unveils Major Organizational Change to Reduce Provider and Clinician Burden and Improve Patient Outcomes.” They are creating the Office of Burden Reduction and Health Informatics with the goal of unifying the agency’s efforts to reduce regulatory and administrative burden and to further the goal of putting patients first. Can’t anyone figure a better way to reduce bureaucracy other than creating a new government office with inherent bureaucracy?