NW Florida Medicare Serving the Panhandle

Medicare Update March 2018

Medicare Update

My how the year is flying by. So I want to share some of the updates on the horizon for Medicare. Let’s look at some of the upcoming Medicare Changes.

Changes to Telehealth Rules

The Continuing Resolution further expands the situations in which providers can obtain Medicare reimbursement for telehealth services. For example, it includes new coverage for telehealth services provided in urban areas for the narrow purpose of stroke care. It also allows Medicare Advantage plans to offer expanded telehealth purposes, which will be treated as original Medicare services for the purposes of calculating payments.

Increased Fraud & Abuse Penalties

The Continuing Resolution increased the maximum criminal and civil fines and penalties associated with a number of healthcare fraud statutes.

• Increasing the maximum criminal penalties from $25,000 to $100,000 per claim, and from five years to 10 years in prison for felony violations under 42 U.S.C. § 1320a-7b, including the Anti-Kickback Statute (AKS), prohibitions on false statements associated with federal healthcare program benefits and the condition/ operation of institutions, and illegal patient admittance and retention practices.

• Increasing fines under the sections of the Civil Monetary Penalty (CMP) Law concerning “improperly filed claims,” including increasing CMPs:

  • From $50,000 to $100,000 for civil penalties for violating the Anti-Kickback Statute, prohibitions on making false records or statements material to false claims, and making false statements in bids or contracts (for example, for Medicare Parts C and D).
  • From $15,000 to $30,000 for providing false information that could reasonably be expected to influence inpatient hospital discharge decisions.
  • From $10,000 to $20,000 for medically unnecessary care, remuneration that could reasonably induce beneficiaries to select a provider, unlicensed physician services, upcoding, certain relationships with excluded individuals, and several other violations.

Drug Companies

Drug company lobbyists are pushing lawmakers to include in the forthcoming appropriations package two small changes to Medicare that could help them reap bigger profits from the federal program.

Johnson & Johnson, Amgen, and Genentech, the makers of several of the most popular “biologic” drugs, are lobbying Republicans to add a provision that ensures that one Medicare program doesn’t pay more for newer “biosimilar” drugs than it does for their products, according to several congressional aides and lobbyists.

Therapy Caps

The federal budget agreement Congress approved last month removes annual caps on how much Medicare pays for physical, occupational or speech therapy and streamlines the medical review process. It applies to people in traditional Medicare as well as those with private Medicare Advantage policies.

As of Jan. 1, Medicare beneficiaries are eligible for therapy indefinitely as long as their doctor—or in some states, physician assistant, clinical nurse specialist or nurse practitioner—confirms their need for therapy and they continue to meet other requirements. The Centers for Medicare & Medicaid Services (CMS) last month notified health care providers about the change.

And under a 2013 court settlement, they won’t lose coverage simply because they have a chronic disease that doesn’t get better.

“Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that,” said Judith Stein, executive director of the Center for Medicare Advocacy.


In a proposal paper released last month, the Centers for Medicare and Medicaid Services (CMS) laid out two policies affecting opioid prescriptions obtained through Medicare Part D that would come into effect starting in 2019.

One would call for a “hard edit” of opioid prescriptions made to patients on Medicare Part D that exceed a specific cumulative daily dose—the equivalent of 90 milligrams of morphine (MME). When pharmacists go to fill these prescriptions by submitting the request electronically, they would encounter a denial of payment from the insurer or pharmacy benefit manager followed by a brief explanation of why. Patients could still be allowed to have their prescription paid by Medicare, but only after an appeal and acknowledgment from their doctor that they qualify for certain exceptions, such as having cancer, being terminally ill, or otherwise having pre-existing approval for a higher dose.

The second proposed policy would tell Part D plan providers to deny coverage for prescriptions made to first-time opioid users, flagged via a database that tracks prescriptions obtained through Part-D, that provide more than a 7-day-long supply, regardless of their diagnosis.

Medicare Cards

In April, the government will start sending out new Medicare cards, launching a massive, yearlong effort to alter how 59 million people enrolled in the federal health insurance program are identified.

Historically, Medicare ID cards have been stamped with the Social Security numbers of members — currently, about 50 million seniors and 9 million people with serious disabilities. But that’s been problematic: If a wallet or purse were stolen, a thief could use that information, along with an address or birthdate on a driver’s license, to steal someone’s identity.

The new cards address these concerns by removing each member’s Social Security number and replacing it with a new, randomly generated 11-digit “Medicare number” (some capital letters are included). This will be used to verify eligibility for services and for billing purposes going forward.

Stay tuned for more important Medicare Changes coming to you every month by your truly Mark Garrett, Your Medicare Agent.

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