DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 455 Office of Inspector General Medicaid; Revisions to State Medicaid Fraud Control Unit Rules
This final rule amends the regulation governing State Medicaid Fraud Control Units (MFCUs or Units). The rule incorporates statutory changes affecting the Units as well as policy and practice changes that have occurred since the regulation was initially issued in 1978. These changes include a recognition of OIG’s delegated authority; Unit authority, functions, and responsibilities; disallowances; and issues related to organization, prosecutorial authority, staffing, recertification, and the Units’ relationship with Medicaid agencies. The rule is designed to assist the MFCUs in understanding their authorities and responsibilities under the grant program, clarify the flexibilities the MFCUs have to operate their programs, and reduce administrative burden, where appropriate, by eliminating duplicative and unnecessary reporting requirements. For more information, go to: https://www.govinfo.gov/content/pkg/FR-2019-03-22/html/2019-05362.htm.
TITLE 1. ADMINISTRATION PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 371. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY SUBCHAPTER F. INVESTIGATIONS 1 TAC §§371.1305, 371.1307, 371.1312
The Texas Health and Human Services Commission (HHSC) proposes amendments to §371.1305, concerning Preliminary Investigation, and §371.1307, concerning Full Investigation. HHSC also proposes new §371.1312, concerning Recipient Investigations.
The Texas Government Code §531.102(p) was added by Senate Bill (S.B.) 207, 85th Legislature, 2017 to require HHSC and the Office of Inspector General (OIG) to adopt rules establishing criteria for opening, prioritizing, and closing cases. Accordingly, HHSC and OIG adopted rule §371.1305, which established the criteria mandated by the statute. In its report to the 85th Legislature in February 2017, the Sunset Commission noted agency implementation as partially complete and recommended that OIG adopt rules relating to prioritizing recipient cases and guiding field investigators in closing cases.
The proposed amendments and the new rule:
- Formalize criteria for prioritizing and closing cases.
- Delineate inclusive lists of specific criteria that will be considered by investigators when they consider whether a particular preliminary, full-scale, or recipient investigation should be closed. In the case of preliminary investigations, investigators also consider this criteria when deciding whether a case should be pursued as a full-scale investigation.
- Requires that recipient cases be prioritized according to the highest potential for recovery and federal timeliness requirements.
- These proposed amendments do not change OIG’s approach to opening, closing, and prioritizing investigations, they only provide more detail as to the criteria that the agency’s investigators apply when they evaluate a recipient case or whether a case should be closed.
- Proposed amendment to §371.1305 adds a new section (e), which delineates an inclusive list of criteria that OIG may consider when determining whether to close a preliminary investigation. The current section (e) is relettered to section (f), and current section (f) is relettered to section (g).
- Proposed amendment to §371.1307 adds a new section (b), which delineates an inclusive list of criteria that OIG may consider when determining whether to close a full-scale investigation. Sections have been relettered.
- Proposed new §371.1312 delineates a list of factors OIG considers when prioritizing recipient cases, as well as an inclusive list of criteria that OIG may consider when determining whether to close a recipient case.
Federal News and Information
Provider Enrollment, Chain, and Ownership System (PECOS) FAQ Update
PECOS is an online Medicare enrollment system. CMS has updated the FAQ and contact information.
To access, the:
- FAQ, go to:
- Contact information, go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243418.html?DLPage=1&DLEntries=10&DLFilter=technic&DLSort=0&DLSortDir=descending.
Change Request (CR) Number 11049 Ensuring Only the Active Billing Hospice Can Submit a Revocation
CR 11049 creates a new Common Working File (CWF) edit in Medicare systems to ensure that the provider identifier (the Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN)) on Type of Bill (TOB) 8xB matches the most recent provider CCN on a hospice benefit period. CR 11049 contains no new policy. It revises Medicare systems to administer existing hospice benefit policy more efficiently. Make sure your billing staffs are aware of these edits. This will be implemented on July 1, 2019. You can access CR 11049 at:
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11049.pdf ; or
New Medicare Beneficiary Identifier (MBI) Get It, Use It
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to remove Social Security Numbers from all Medicare cards by April 2019. A new, randomly generated Medicare Beneficiary Identifier, or MBI, is replacing the SSN-based HICN. The new MBI is noticeably different than the HICN. The MBI hyphens on the card are for illustration purposes: don’t include the hyphens or spaces on transactions. The MBI uses numbers 0-9 and all uppercase letters except for S, L, O, I, B, and Z. CMS excludes these letters to avoid confusion when differentiating some letters and numbers. CMS revised this article on March 6, 2019, to add language that the MBI look-up tool can be used to obtain an MBI even for patients in a Medicare Advantage Plan. All other information remains the same.
- A fact sheet discussing the transition to the MBI and the new cards is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/ Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf.
- For more information on https://www.palmettogba.com/Palmetto/Providers.Nsf/files/April_2019_JMHHH_Medicare_Advisory_Final.pdf/$File/April_2019_JMHHH_Medicare_Advisory_Final.pdf
Medicare Beneficiary Identifier (MBI) Look-up Tool
The Medicare Beneficiary Identifier (MBI) Lookup tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. If you do not already have access, sign up at: https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do for access to eServices to use the tool. To read this article, go to: https://www.palmettogba.com/Palmetto/Providers.Nsf/files/April_2019_JMHHH_Medicare_Advisory_Final.pdf/$File/April_2019_JMHHH_Medicare_Advisory_Final.pdf.
Hospice Provider Preview Reports: Review Your Data by March 31
Two reports are available in your Certification and Survey Provider Enhanced Reports (CASPER) non-validation reports folder:
- Hospice provider preview report: Review Hospice Item Set (HIS) quality measure results from the third quarter of 2017 to the second quarter of 2018.
- Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey provider preview report: Review facility-level CAHPS survey results from the third quarter of 2016 to the second quarter of 2018.
Review your HIS and CAHPS results by March 31. If you believe the denominator or other HIS quality metric is inaccurate or if there are errors in the results from the CAHPS survey data, request a CMS review. For more information, go to:
UPDATED PEPPER Retrieval Maps Allow Comparison By State
The PEPPER team has updated the maps that display the PEPPER retrieval rates for PEPPERs accessed via the PEPPER Resources Portal for each state/territory. Percentages reflect the PEPPER release for SNFs, Hospices and LTCHs that was completed April 9, 2018; and for HHAs that was completed July 16, 2018. Please click on a link below to view the maps. States on the interactive maps are color-coded according to their retrieval rates. Click on a state to obtain details such as the number of PEPPERs available in the state via the portal, the number of PEPPERs accessed via the portal, the retrieval rates and a link to the data file for all states/territories in the nation. The maps are updated monthly. https://pepper.cbrpepper.org/Training-Resources/Hospices/PEPPER-Portal-Retrieval-Map
Home Health and Hospice Fee Schedule
Palmetto has released the fee schedule based on the CY 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. The fees are effective January 1, 2019. To access, go to: https://www.palmettogba.com/palmetto/providers.nsf/ls/JM%20Home%20Health%20and%20Hospice~BANNCR5423?opendocument&utm_source=JMHHHL&utm_campaign=JMHHHLs&utm_medium=email.
Texas News and Information
Health and Human Services Commission (HHSC)
Medicaid Hospice Rates
The Medicaid hospice rates were posted to the HHSC rate setting website. You can access them at: https://rad.hhs.texas.gov/sites/rad/files/documents/long-term-svcs/2019/10-2019-hospice-rates.pdf.
Texas Medicaid Healthcare Partnership (TMHP)
Reminder: Eligibility Information Available for Hospice Providers
As a reminder, Hospice providers seeking eligibility information can pull Medicaid Eligibility and Service Authorization Verification (MESAV) using any of the following field combinations through TexMedConnect. This service can be accessed 24 hours a day, 7 days a week.
- Medicaid/Client No. and Last Name
- Medicaid/Client No. and Date of Birth
- Medicaid/Client No. and Social Security Number
- Social Security Number and Last Name
- Social Security Number and Date of Birth (DOB)
- Last Name, First Name, and DOB
|Program Type||Coverage Code|
|Type 12, 11||P|
|Type 13, 51||R|
|Type 01, 03, 07, 08, 09, 10, 14, 15, 18, 19, 20, 21, 22, 29, 37, 40, 43, 44, 45, 46, 47, 48, 55, 61, 63, 67||P or R|
For more information on TexMedConnect and utilizing MESAV, call the TMHP Long Term Care Help Desk at 1-800-626-4117, Option 1. You can access this notification at: file:///C:/Users/Acer/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/KRBT6N81/Reminder%20Eligibility%20Information%20for%20Hospice%20Providers.pdf.