Weekly Roundup - July 3-7, 2023
Physician payment, coding, coverage, and quality reporting news highlights.
With Congress in recess until July 10 and the 4th of July holiday, it was a relatively quiet week – so far.
PAYMENT
CY 2024 Medicare Physician Fee Schedule (PFS) Proposed Rule Clears OMB – Should be Released Shortly. On Friday morning, July 7, 2023, the PFS cleared review from the Office of the Management Budget (OMB). This review is the final step before the release of the proposed regulations. We anticipate the PFS will be released Friday afternoon or Monday afternoon. The PFS sets payment rates and policies for over 7,000 services physicians and other qualified healthcare professionals provide. While the proposed policies are kept under wraps, some educated prognosticating can be done. Continue reading HERE for more details.
As of Friday morning, the CY 2024 Hospital Outpatient Prospective Payment System Proposed Rule was still under review at the OMB.
Provider Relief Fund (PRF) Reporting Period 5 Portal Now Open. During the pandemic, PRF payments were made to eligible providers with health-related expenses and lost revenues attributable to COVID-19. Providers who received one or more PRF (General or Targeted) and/or American Rescue Plan Rural payments exceeding $10,000, in the aggregate, from January 1 to June 30, 2022, must report on their use of funds during Reporting Period 5 to comply with PRF Reporting Requirements. The PRF Reporting Portal is open from Saturday, July 1, to Saturday, September 30, 2023, at 11:59 p.m.
PAYMENT INNOVATION
Providers Missing Their Alternative Payment Model (APM) Incentive Payments Should Verify Medicare Billing Information. Eligible clinicians who were Qualifying APM Participants (QPs) based on their 2021 performance should have begun receiving their 2023 5% APM Incentive Payments earlier this summer. These payments are automatic and generally do not require action by providers. The Medicare agency is requesting providers that have not begun to receive their payment should check the 2023 QP Notice for APM Incentive Payment Zip File on the QPP Resource Library. This file indicates if a provider needs to verify their Medicare billing information. Verification must be completed by September 1, 2023. More information is available on the Quality Payment Program website.
COVERAGE
Medicare Announces Study that Meets Coverage with Evidence Development (CED) Requirements for Newly Approved Alzheimer's Drug. On July 6, 2023, the U.S. Food and Drug Administration (FDA) granted traditional approval of Leqembi® (lecanemab, Eisai/Biogen) for the treatment of early Alzheimer's disease with confirmation of elevated amyloid beta. The drug, which is given as an IV infusion once every two weeks, has been shown to moderately slow cognitive decline in people with early-stage disease.
As a result of the recent FDA approval, the Medicare agency authorized coverage of the drug, although physicians will be required to enroll patients in a registry which is a criteria for coverage under Coverage with Evidence Development (CED). Medicare has approved a study, Prospective Study on Anti-Amyloid-β Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease Coverage of Evidence Development (The Anti-Aβ mAb CED Study), that has been determined to meet the requirements for coverage under CED. Registry details are available HERE. This approach is consistent with a plan announced last month.
Until now, Medicare has paid for Leqembi only for patients in certain clinical trials. The Alzheimer Association welcomed the agency’s announcement of broader coverage after FDA approval. Many advocates and other stakeholders felt the previous coverage for patients in certain clinical trials was too restrictive. On Wednesday, before the FDA or Medicare agency’s announcements, the House Energy and Commerce Committee Chair released a statement that “traditional coverage” should be granted to the drug – instead of what was granted – CED, which requires enrolling patients in a registry.
Leqembi has a list price of $26,500 per year. Patients with traditional Medicare would be responsible for 20% coinsurance, although those with Medigap or supplemental insurance may be responsible for less.
For more information and questions, please contact:
Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
www.madhani-health.com
Tel: (202) 679-2977