Medicare Compliance & Reimbursement

OIG final rule welcomes the shift to value-based care.

As CMS transitions from its Sustainable Growth Rate (SGR) formula to MACRA’s Quality Payment Program (QPP), the OIG continues to offer compliance guidance and incentive for abiding to its regulations.

Background. On Dec. 7, 2016, the Federal Register published a final rule that seemed to speak to many providers’ frustrations about the AKS rules regarding safe harbors. The report offered an olive branch to physicians and their business partners with revisions to old standbys that suggested easing up on regulations to promote the delivery of coordinated care.

“Although the rulemaking finalizes ten new AKS and beneficiary inducement CMP exceptions/safe harbors, a number of them apply only in very narrow circumstances,” says Christopher G. Janney, Esq. of Dentons US LLP in Washington D.C. “Three of them, however, are broadly applicable and significant.”

Here are the three most important ones that Janney suggests you know:

• The new AKS safe harbor for local transportation
• The new CMP exception for items and services that improve a beneficiary’s ability to obtain covered care and pose a low risk of program harm
• The new CMP exception for medical items and services provided to those in financial need

Some of the other CMP exceptions and safe harbors are:

• Cost-sharing waivers for Medicare Part D beneficiaries with financial need
• Cost-sharing waivers for emergency ambulance services
• Discounts for drugs under the Medicare Coverage Gap Discount Program
• Copayment reductions for certain outpatient services
• Coupons, rebates, and rewards for certain retailers
• Medicare Advantage organizations and federally-qualified health centers changes
• Reductions on the first prescription of generic drugs

Here’s The Caveat

The new OIG offerings are a boon to the industry at large, but stipulations do exist and there are some exceptions.

“Each of these safe harbors and exceptions have multiple conditions,” Janney explains. “Moreover, several of these conditions will require providers to make sometimes difficult judgment calls as to whether a particular offering is on the right side of what remain somewhat blurry lines.”

Local transport. For example, under the AKS safe harbor for local transportation the beneficiary receiving the service must be an “established patient”—a person who has selected and initiated contact with a provider or supplier to schedule an appointment or who has given consent to someone to do it for them—and has a medically necessary need for it, the final rule suggests. In addition, the transportation covers only 25 urban miles or 50 rural miles to a home health facility, pharmacy, or lab and will not be covered if the transport is air, luxury, or ambulance-level transportation.

Despite the minutia, the new safe harbor options echo governmental efforts to put patients’ needs first. “Overall, however, these provisions significantly expand the universe of free and discounted items and services that hospitals, physicians, and other providers may furnish to Medicare, Medicaid, and other federal health care program beneficiaries,” Janney maintains.

MACRA is at the Heart

The past few months have seen one initiative after another fall into place, promoting quality, patient-centered care. With MACRA’s launch less than 30 days away, the HHS, CMS, and their affiliates have created a stairway to success for those providers and suppliers willing to step up.

“There is no question that many of these changes are being driven by the seemingly inexorable move from a fundamentally ‘fee-for-service’ reimbursement model to a fundamentally ‘managed care’ reimbursement model,” Janney explains. “The AKS and beneficiary inducement CMP are creatures of a fee-for-service world; all other things being equal, their policy objectives do not align well with a managed care world; and Congress, CMS and HHS-OIG recognize this, as reflected in rulemakings such as this.”

Final note: In the past, commercially-insured patients have reaped many of the benefits that fall under these safe harbor changes while those covered under federal healthcare have been left to the wayside. “Many coupon, discount, and other reward programs have historically carved-out Medicare and Medicare beneficiaries,” Janney says. “These new rulemakings are, at least in part, an effort to level the playing field a bit.”