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CMS Clarifies Claims Processing Changes

A recent special issue of the Medicare Learning Network (MLN) Newsletter outlines the timing of claims processing system changes related to some of the Medicare payment provisions included in the Bipartisan Budget Act (BBA) of 2018, which was signed into law on Feb. 9, 2018. The LeadingAge NY summary of the BBA is available here.

The newsletter specifies that:

  • Those provisions that are effective retroactive to Jan. 1, 2018 (therapy cap repeal, Part B rate change for certain areas including much of upstate New York, extension of ambulance payment increases) are expected to be implemented retroactively to Jan. 1st without any new provider action required;
  • Claims processing system changes for provisions related to low-volume hospitals, the Medicare-Dependent Hospital Program, and the site neutral payment rate for long-term care hospital (LTCH) discharges are under development and expected to be implemented in the spring; and
  • For Medicare provisions in the new law with future effective dates (home health rural add-on and non-Emergency ESRD ambulance rate reduction), Medicare claims processing system changes are under development for implementation on the provisions' effective dates. More information related to these changes is forthcoming.

The Centers for Medicare and Medicaid Services (CMS) will begin the process of releasing claims that had been held briefly after expiration of the therapy caps exceptions process. CMS will release for processing the held claims based on the date the claim was received (i.e., on a first-in, first-out basis) until no claims are being held. This process will be accomplished as quickly as possible while staying within the requirements for the volume of claims that Medicare Administrative Contractors (MACs) can release on a given day.

The BBA raises the Work Geographic Practice Cost Index (GPCI) to 1.000 for all localities that until now had a Work GPCI of less than 1.000. The Work GPCI Floor impacts the fees for all codes paid under the Medicare Physician Fee Schedule (MPFS) for affected localities. Upstate New York counties in Region 5 (which includes all upstate counties north of Westchester other than Columbia, Delaware, Dutchess, Greene, Orange, Putnam, Sullivan, and Ulster) will see a slight Part B rate increase. No new provider action is necessary for implementation. The Medicare Physician Fee Schedule reflecting this change is available for download on the Government Service web page here.

CMS also notes that while the BBA requires that the FY 2019 update to the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) rates be 2.4 percent, currently available data suggests that the projected update would have been 1.8 percent. This means that, based on data currently available, SNFs would receive a FY 2019 update of 2.4 percent rather than the currently projected update of 1.8 percent because of this BBA provision.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841