Medicare Information

Hello Everyone,

Please enjoy the information contained in this edition of Frontier Focus. Please be sure to share it with your members, colleagues, providers and office billing staff. Thank you for your continued efforts to broadcast Medicare information to the providers in Region VIII.





Table of Contents



1. Upcoming Training for the Medicare Part B Drugs Competitive Acquisition Program (CAP)



2. Award of New A/B MAC Contracts



3. “Medicare’s Practical Guide to the E-Prescribing Incentive Program” is now available online!



4. Medicare Proposes Revised Coverage Policy for Bariatric Surgery As a Diabetes Treatment



5. CMS Issues Improper Payment Rates for Medicare, Medicaid, and SCHIP



6. New Institutional NCCI Edits to Be Applied to Claims



7. Medicare Publishes New Information on Quality of Care at Dialysis Facilities



8. Gustave and Ike Waivers Expire



9. New From the Medicare Learning Network



10. November Flu Shot Reminder



11. Extra Help for Beneficiaries Paying for Prescription Drugs









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1. Upcoming Training for the Medicare Part B Drugs Competitive Acquisition Program (CAP)



Noridian Administrative Services, the designated carrier for the CAP, offers interactive, online workshops about the CAP for Part B Drugs and Biologicals. These workshops train CAP vendors and elected physicians on a variety of CAP topics, including how to transition out of the CAP at the end of 2008 due to the postponement of the program for 2009. NAS staff will also be available to answer questions. Interested parties may view additional information about and register for these workshops on the Noridian website at:

https://www.noridianmedicare.com/cap_drug/train/schedule.html

A workshop will be held on the following date:

11/24/08 at 2:00 pm CST
Additional information about the CAP and the 2009 postponement is available at: http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp

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2. Award of New A/B MAC Contracts



CMS SELECTS NATIONAL HERITAGE INSURANCE CORPORATION

TO ADMINISTER MEDICARE CLAIMS PAYMENT IN

MAINE, MASSACHUSETTS, NEW HAMPSHIRE, RHODE ISLAND AND VERMONT



The Centers for Medicare & Medicaid Services (CMS) recently announced that National Heritage Insurance Corporation (NHIC) has been awarded a contract of up to five years for the combined administration of Part A and Part B Medicare claims payment in Maine, Massachusetts, New Hampshire, Rhode Island and Vermont.



NHIC will serve as the first point of contact for the processing and payment of Medicare fee-for-service claims from hospitals, skilled nursing facilities, physicians and other health care practitioners in Maine, Massachusetts, New Hampshire, Rhode Island and Vermont. The new Part A/Part B Medicare Administrative Contractor (A/B MAC) was selected using competitive procedures in accordance with federal procurement rules.



The new contractor will take claims payment work now performed by three fiscal intermediaries and two carriers in Maine, Massachusetts, New Hampshire, Rhode Island and Vermont. The A/B MAC contract, which has an approximate value of $176 million over five years, will fulfill the requirements of the Medicare Modernization Act’s (MMA) contracting reform provisions.



As the A/B MAC contractor, NHIC will immediately begin implementation activities and will assume full responsibility for the claims processing work in its five-state jurisdiction no later than May 2009. NHIC will be reaching out to providers and state medical associations to provide education and information about the implementation. For more details, visit NHIC’s website at www.medicarenhic.com.



CMS awarded the first A/B MAC contract in July 2006 to Noridian Administrative Services, LLC, headquartered in Fargo, N.D. The list of new contractors and the states they cover, along with other information, can be found at http://www.cms.hhs.gov/MedicareContractingReform/



To read the CMS press release issued 11/19, click here: http://www.cms.hhs.gov/apps/media/press_releases.asp

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3. “Medicare’s Practical Guide to the E-Prescribing Incentive Program” is now available online!



The guide explains the e-prescribing incentive program, how eligible professionals can participate, and how to choose a qualified e-prescribing system. To read or print the guide, visit: http://www.cms.hhs.gov/partnerships/downloads/11399.pdf.



By adopting e-prescribing through Medicare’s program, eligible professionals can save time, enhance office and pharmacy productivity, and improve patient safety and quality of care while earning incentives from Medicare.



For additional information about e-prescribing, you can also visit:

www.cms.hhs.gov/PQRI. Select “E-prescribing Incentive Program”;
www.cms.hhs.gov/eprescribing. (for information on Part D e-prescribing standards that will be effective April 1, 2009); and
www.ehealthinitiative.org to download “A Clinician’s Guide to Electronic Prescribing.”


Continuing Education Credits Available

On October 6–7, 2008, CMS and 34 partner organizations hosted the National E-Prescribing Conference to promote and explain the potential of e-prescribing to improve health care in the United States. Sessions included the e-prescribing incentive payment program; strategies and tools for integrating e-prescribing with current health care delivery practices; and privacy, security, and risk management implications.



The Massachusetts Medical Society and the American Pharmacists Association will provide continuing education for selected presentations from the conference through an online education portal. Available credits are a maximum of 22.5 AMA PRA Category 1 Credits™, and Continuing Education for pharmacists (up to 13.25 hours of continuing education credit (1.325 CEUs)). To view or listen to the presentations, and complete an online test on each segment, go to www.massmed.org/cme/CMS_eprescribing.



Additional information is available on the National E-Prescribing Conference site at http://www.epsilonregistration.com/er/EventHomePage/CustomPage.jsp?ActivityID=378&ItemID=1117.



The Centers for Medicare & Medicaid Services looks forward to working with you on the adoption of e-prescribing and implementation of the incentive program.

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4. Medicare Proposes Revised Coverage Policy for Bariatric Surgery as a Diabetes Treatment



CMS Seeks Comments from Public on Proposal to Limit Coverage to Morbidly Obese Patients



The Centers for Medicare & Medicaid Services (CMS) announced today its proposal to clarify its policies for Medicare coverage of bariatric surgery as a treatment for beneficiaries with type 2 (or non-insulin-dependent) diabetes.



Following an extensive evidence review, CMS proposes to revise its existing coverage policy for bariatric surgery. The proposed decision notes that type 2 diabetes is one of the co-morbidities CMS would consider in determining whether bariatric surgery would be covered for a Medicare beneficiary who is morbidly obese. An individual with a body-mass index (BMI) of at least 35 is considered morbidly obese.





To read the CMS Press release issued today (11/07/08) click here: http://www.cms.hhs.gov/apps/media/press_releases.asp



Today’s proposed decision memorandum is available on CMS’ Coverage Web site at http://www.cms.hhs.gov/center/coverage.asp.

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5. CMS Issues Improper Payment Rates for Medicare, Medicaid, and SCHIP



CMS today reported it protected roughly $400 million of taxpayer dollars as improper payments for Medicare fee-for-service (FFS) decreased from 3.9 percent in Fiscal Year (FY) 2007 to 3.6 percent, or $10.4 billion, in FY 2008. The Medicare, Medicaid and SCHIP improper payment rates are issued annually as part of the HHS Agency Financial Report.



In addition to improved Medicare FFS payments for FY 2008, CMS reports its first Medicare Advantage improper payment rate of 10.6 percent, or $6.8 billion, in payments made in Calendar Year (CY) 2006. Also being reported for the first time are the FY 2007 national composite error rates for Medicaid and for SCHIP. The Medicaid composite error rate is 10.5 percent, or $32.7 billion of which the federal share is $18.6 billion, and, for SCHIP, the rate is 14.7 percent, or $1.2 billion, with a federal share of $0.8 billion.



To read the complete CMS Press release issued today (11/07/08) click here: http://www.cms.hhs.gov/apps/media/press_releases.asp

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6. New Institutional NCCI Edits to Be Applied to Claims



NCCI edits are updated quarterly and the institutional version is one calendar quarter behind the physician version. In the past, the Outpatient Code Editor (OCE) has not applied the NCCI edits for the following categories of services: anesthesiology, evaluation and management, and mental health services. Effective 1/1/09, these categorical exclusions will be removed and there will be a large number of new institutional NCCI edits applied to claims. These institutional NCCI edits will be available on or about 1/1/09 on the following CMS Website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp#TopOfPage .



To review the types of NCCI edits that were previously excluded from the institutional version but are currently included in the physician version for these categories, refer to the NCCI files on the following site: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage . One may use anesthesiology, evaluation and management, or mental health services CPT or Level II HCPCS codes to search these files. A subset of the corresponding edits in the physician version is being added to the institutional version. Consistent with longstanding practice, CMS makes specific decisions about NCCI edits that are appropriate for facilities, incorporating comments on potential edits from relevant professional associations and, therefore, the institutional NCCI edits may differ from the physician NCCI edits.



Affected providers should begin immediately to educate their staff about the application of the additional categories of NCCI edits to their claims. Note that at this time no additional providers will be subject to NCCI edits.

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7. Medicare Publishes New Information on Quality of Care at Dialysis Facilities



The Centers for Medicare & Medicaid Services (CMS) recently announced important additions to the Dialysis Facility Compare consumer Web site (http://www.medicare.gov/dialysis) that will give consumers even better insight into the quality of care provided by their local dialysis patient facilities. The improvements include two new quality measures that demonstrate how well dialysis patients are treated for anemia (low red blood cell count) as well as updated information that will help patients better understand survival rates by facility.



Dialysis Facility Compare links consumers with detailed information about the 4,700 dialysis facilities certified by Medicare, and allows users to compare facilities in a geographic region. Users can review information about the size of the facility, the types of dialysis offered, the facilities’ ownership, and whether the facility offers evening treatment shifts. Consumers can also compare dialysis facilities based on three key quality measures— how well patients at a facility have their anemia under control, how well patients at a facility have waste removed from their blood during dialysis, and whether the patients treated at a facility generally live as long as expected. Dialysis Facility Compare also links users to resources that support family members and specialized groups of kidney patients.



“Dialysis Facility Compare is yet another tool that equips consumers with the tools they need to seek better, value-based health care,” said CMS Acting Administrator Kerry Weems. “Adding more information on the Dialysis Facility Compare Web site about anemia—a condition that affects many dialysis patients—and patient survival will help us all learn more about how well the country’s dialysis facilities are serving Medicare beneficiaries and the entire health care system.”



Dialysis Facility Compare has featured information about anemia control since the Web site was launched in 2001. Historically, the Web site has shown the percentage of patients in a facility whose hematocrit levels were at 33 percent or more (or hemoglobin levels of 11 g/dL or more), based on clinical practice guidelines at the time. However, recent evidence about increased risk of certain adverse events associated with the use of erythropoiesis stimulating agents (ESAs), which are used to treat anemia, has raised concerns about patients who hemogloblin levels are too high as well as patients whose hemoglobin levels are too low. The Food and Drug Administration has responded by requiring manufacturers to develop a Medication Guide and to ensure that this information is provided to patients. As a result, Dialysis Facility Compare will now feature two anemia measures—one measure will show the percentage of patients whose hemoglobin levels are considered too low (i.e., below 10 g/dL) and a second measure will show the percentage of patients whose hemoglobin levels are considered too high (i.e., above 12 g/dL).



“These two new measures better reflect recent medical evidence about the challenges of managing anemia,” said CMS Chief Medical Officer and Director of the agency’s Office of Clinical Standards & Quality, Barry Straube, M.D. “Our new measures will help patients and health care providers to better understand how a facility’s patients are treated for anemia, a condition for which studies have shown that over- and under-treatment can affect patients’ health status and quality of life.”



In addition to adding new information about anemia treatment, CMS has also updated the way it reports patient survival rates on Dialysis Facility Compare. Since 2001, CMS has reported survival rates by comparing a facility's expected patient survival rate to its actual patient survival rate. (The expected survival rate takes into account the patients’ personal characteristics, health, and dialysis history. The actual survival rate is the rate each facility reports to CMS about how many patients have survived in a given timeframe.) Facilities’ survival rates were then rated as belonging to one of three categories: “Better than Expected” (by 20 percent or more), “As Expected” or “Worse than Expected” (by 20 percent or more). This method of calculating patient survival resulted in a finding of “As Expected” for 94 percent of dialysis facilities nationwide, with only 3 percent in the “Better” or “Worse” categories, respectively.



To help consumers make better distinctions among facilities’ survival rates, CMS updated the statistical method it used to classify facilities in the three categories. While consumers will continue to see facilities placed into one of these categories, they will find fewer facilities in the “As Expected” category, and more facilities in the “Better” or “Worse” categories.



These enhancements are only one part of CMS’ plans to improve the quality of care in America’s dialysis facilities. Earlier this year, CMS revised its conditions for coverage regulations for the first time in over 30 years, which updated the health and safety standards that dialysis facilities must meet to receive Medicare coverage. A key element of this regulation was the development of a new Web-based data entry framework for dialysis facilities nationwide, which will eventually provide substantially more detailed information for consumers as part of Dialysis Facility Compare. CMS is also working to implement a value-based purchasing program to pay for dialysis services, which will reward facilities for providing high-quality, efficient, and effective care.



The Dialysis Facility Compare Web site can be viewed at www.medicare.gov/dialysis. Other provider compare Websites are available through www.medicare.gov or directly at www.medicare.gov/HHCompare for information about home health agencies and nursing homes. For information on hospitals, visit www.hospitalcompare.hhs.gov. CMS also provides comparative resources about Medicare Advantage (www.medicare.gov/MPPF) and Medicare prescription drug plans (www.medicare.gov/MPDPF).

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8. Gustave and Ike Waivers Expire



In September 2008, the Centers for Medicare & Medicaid Services (CMS) issued guidance that discussed the statutory requirement under Medicare’s Skilled Nursing Facility (SNF) benefit for a 3-day prior hospital stay, and the inability of beneficiaries who were evacuated or transferred as a result of Hurricanes Gustav and Ike to meet this requirement. This guidance provided temporary emergency coverage of SNF services that are not post-hospital SNF services under our authority in section 1812(f) of the Social Security Act (the Act), for those beneficiaries who are evacuated, transferred, or otherwise dislocated as a result of the hurricanes.



In addition, for beneficiaries who (prior to the hurricanes) had been recently discharged from an SNF after utilizing some or all of their available SNF benefits, this guidance addressed the inability to meet the requirement to end an existing Medicare benefit period (or “spell of illness”) before renewing SNF benefits. Under the authority of section 1812(f) of the Social Security Act (the Act), this policy enabled such beneficiaries to receive up to an additional 100 days of SNF Part A benefits for care needed as a result of the hurricanes, without first having to end a spell of illness by being discharged to custodial or non-institutional care for a 60-day period.



Unlike the general waivers issued in response to the hurricanes under the authority of section 1135 of the Act, these two SNF-related policies were not limited to States designated as emergency areas. Rather, they would apply to all beneficiaries who were evacuated from an emergency area as a result of the hurricanes, regardless of where the “host” SNF providing post-hurricane care was located. In addition, these two SNF‑related policies would remain in effect until such time as CMS issued a notification that normal procedures would resume.



We hereby announce the termination of these SNF-related policies concurrently with the 90-day expiration of the Public Health Emergencies (PHEs) declared for Hurricanes Gustav and Ike. The waivers and modifications granted under the section 1135 waiver authority also terminate concurrently with the expiration of the PHEs. The expiration dates for the PHEs are shown below. Accordingly, effective with SNF admissions occurring on or after the termination dates listed below, the Internet-Only Manual instructions for determining compliance with the SNF benefit’s prior hospitalization and benefit period requirements shall apply.



Finally, all program policies and Questions and Answers that implemented modifications to program requirements under the section 1135 waiver authority for Hurricanes Gustav and Ike are no longer applicable on and after the dates stated below. Therefore, claims with dates of service on or after the termination dates cited below will follow all normal program requirements.



Hurricane(s) State(s) §1812(f)/1135 Waiver Term. Dates



Gustav Mississippi, Alabama November 29, 2008



Gustav and Ike Texas December 10, 2008



Gustav and Ike Louisiana December 12, 2008

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9. New From the Medicare Learning Network



The Adult Immunizations (October 2008) brochure for health care providers has been updated and is now available in downloadable PDF format from the Centers for Medicare & Medicaid Services Medicare Learning Network. This brochure provides an overview of Medicare’s coverage of influenza, pneumococcal, and hepatitis B vaccines and their administration. To view, download, and print, please go to http://www.cms.hhs.gov/MLNProducts/downloads/Adult_Immunization.pdf on the CMS website.

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10. November Flu Shot Reminder



Flu season is here! Medicare patients give many reasons for not getting their annual flu shot, including—“It causes the flu"; "I don’t need it"; "It has side effects"; "It’s not effective"; "I didn’t think about it"; "I don’t like needles!” The fact is that every year in the United States, on average, about 36,000 people die from influenza. Greater than 90 percent of these deaths occur in individuals 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk with your Medicare patients about the importance of getting an annual flu shot--and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu. Remember - Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug.



For information about Medicare’s coverage of the influenza virus vaccine and its administration as well as related educational resources for health care professionals and their staff, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS website. To download the Medicare Part B Immunization Billing quick reference chart, go to http://www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf on the CMS website. A copy of this quick reference chart can be ordered, free of charge, by going to the MLN Products web page and clicking on “MLN Product Ordering Page” in the Related Links Inside CMS section of the web page.

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11. Extra Help for Beneficiaries Paying for Prescription Drugs



Do You Know Someone Who Is Having Trouble Paying For Prescription Drugs?

Medicare Can Help!



If an individual has limited income and resources, they may qualify for extra help from Medicare. It could be worth over $3,300 in savings on prescription drug costs per year.
Encourage people with Medicare to file for Extra Help online: https://s044a90.ssa.gov/apps6z/i1020/main.html or by calling Social Security at 1-800-772-1213 to apply over the phone.
State Health Insurance Information Program (SHIP) offices can assist with the application. Find contact information for a local SHIP Counselor at http://www.medicare.gov/contacts/static/allStateContacts.asp or by calling
1-800-MEDICARE.

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Lucretia James

Centers for Medicare & Medicaid Services

Region VIII

1600 Broadway, Suite 700

Denver, CO 80202

(303) 844-1568

lucretia.james@cms.hhs.gov