Navigating CMS Regulations

Covid, OPPS and medical necessity certificates are reported here.

There is good news on the COVID-19 public health emergency (PHE) front. We now know the PHE will remain in effect at least until January 2023. But the Centers for Medicare & Medicaid Services (CMS) scared us last week by publishing a roadmap to ending the PHE. Some thought that this was the promised 60-day notice that the PHE would end in October, but this notice was simply an update of many of the CMS COVID-19 documents including as the listing of the waivers, but many contain added information on what will happen when the PHE does end. In addition, it was published 56 days prior to the next renewal date so it couldn’t possibly be considered 60-day notice. It is crucial that hospital compliance teams review this document to be prepared when the PHE finally is allowed to expire but until that time, you may continue to use the COVID-19 waivers for another few months.

On the good news front, you may have heard that the Food and Drug Administration (FDA) will now allow hearing aids to be sold over the counter and online. This is welcome news to many with hearing loss, as these devices currently are very expensive, costing thousands of dollars. But it will not be a free-for-all on Amazon and eBay. The devices will continue to be regulated by the FDA. The final rule is 200 pages so manufacturers will need to review that carefully and be sure their devices and marketing materials meet the FDA standards.

And in the same arena, in the Outpatient Prospective Payment System (OPPS) proposed rule, CMS is proposing to pay for some routine dental care. Now it would be great if they covered routine dental care for all Medicare patients, but their proposal is to only cover it when the dental care is, as they describe, inextricably linked to, and substantially related and integral to, the clinical success of other covered medical services. In lay terms, that means they will pay for it prior to a patient having a joint replacement or valve replacement or transplant. This is certainly a welcome start for patients and for surgeons. I expect that CMS will soon develop a process to allow dentists to submit claims for payment as most dentists have few or no dealings with Medicare.

Finally, starting Jan. 1, CMS is eliminating all certificates of medical necessity. These are required now for some durable medical equipment and oxygen and physicians universally hate them so this should come as a welcome relief.

But I suspect the DME, and oxygen companies won’t be as excited since they can use the certificate as documented proof the equipment is medically necessary. If a doctor just writes an oxygen order on a prescription pad, as appears to be allowed, the supplier is going to be less certain the patient meets the medical necessity requirements and if audited the suppliers are the ones that won’t get paid, not the doctor.

I am sure we will hear more on this as the new year approaches.

Programming note: Listen every Monday morning when Dr. Hirsch makes his Monday Rounds on Monitor Mondays 10 Eastern and sponsored by R1-RCM.