Category Archives: Medicaid

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Notes on Day 4 of the JPMorgan Healthcare Conference

Some interesting presentations on the last day of the JPMorgan Healthcare Conference that concentrated on common themes – the increasing importance of ancillary business line to bolster core business revenue and of filling in holes to achieve scale and full-service offerings. Genesis Healthcare – The largest U.S. skilled nursing facility (SNF) provider, which also is … Continue Reading

Looking Forward/Looking Backward – Day 1 Notes from the JPMorgan Healthcare Conference

A large amount of wind, much discussion about the U.S healthcare, and the public getting soaked again – if you were thinking about Washington, DC and the new Congress, you’re 3,000 miles away from the action. This is the week of the annual JP Morgan Healthcare conference in San Francisco, with many thousands of healthcare … Continue Reading

House Republicans Push Back on Medicare’s New Mandatory Bundled Payment Models

On July 25, 2016, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that promises to deliver coordinated, high-quality care for Medicare beneficiaries. The proposed rule (effective July 1, 2017) establishes a mandatory bundled payment program for cardiac care and expands the existing hip and knee bundled payment initiative that launched earlier … Continue Reading

New Affordable Care Act and Medicaid Regulations Will Require Covered Entities Providing Healthcare Programs and Services to Have Accessible Websites

There has been a proliferation of ADA lawsuits alleging that websites are not accessible to the blind or deaf.  Individuals who are blind or have low vision may require assistive devices and specialized software to access the Internet.  These devices often include software that enables them to magnify the content of a web page, reads … Continue Reading

The Overpayment Rule and the Implied False Claims Theory: “What You Don’t Know Can Still Hurt You”

In 2010, the Affordable Care Act (“ACA”) enacted new rules governing overpayments made by the Medicare and Medicaid programs. Under these rules, providers have 60 days from the date that the overpayment has been identified to return the overpayment or face penalties and treble damages under the False Claims Act (“FCA”).  As described below, recent … Continue Reading

CMS Grants Extension to Apply for 2015 Meaningful Use Hardship Exemption

The Centers for Medicare and Medicaid Services (“CMS”) continues to work to ensure it is responsive to providers who tried to meet meaningful use standards in 2015 but faced hardships in their efforts. Eligible professionals, eligible hospitals & critical access hospitals (“CAH”) now have until July 1, 2016 to apply to CMS for the Medicare … Continue Reading

CMS Clarifies 60 Day Overpayment Rule

The Department of Health and Human Services’ (HHS) Center for Medicare and Medicaid Services (CMS), is set to publish a final rule that will provide some much needed relief to healthcare providers from the burdens of the so-called 60-Day Overpayment Rule.  The final rule clarifies (1) the 60 day period for refunding overpayments is not … Continue Reading

The Next Rx: New Medicare Part D Initiative Advances Role of Medication Management in Reform

Medicare Part D’s Medication Therapy Management (MTM) program intends to optimize clinical benefits and avoid drug-related problems among eligible beneficiaries. MTM services—involving pharmaceutical and clinical interventions—are offered at no cost to beneficiaries who meet criteria related to annual Part D drug costs, the prevalence of chronic diseases and number of prescription drugs.[1]… Continue Reading

CMS Proposes Mandatory Hospital Participation in New Bundled Payment Program for Hip and Knee Replacements

On July 14th, 2015, the Centers for Medicare and Medicaid’s (CMS) latest proposed rule (Rule) introduced a new alternative payment model. The Rule proposes CMS’ latest alternative payment model known as the Comprehensive Care for Joint Replacement (CCJR) Model. The model is targeted at hospitals that do not currently participate in the CMS Bundled Payments … Continue Reading

Thirteen Years of the Same Rules and Now Big Proposed Changes to the Regulation of Medicaid Managed Care Plans

On June 1, 2015, the Centers for Medicare and Medicaid Services (“CMS”) published a newly proposed rule that would change the way the agency regulates Medicaid managed care plans, the first regulation of its kind since 2002.  The proposed rule seeks to address issues related to the healthcare experience of Medicaid and Children’s Health Insurance … Continue Reading

Proposed Managed Care Rules Leave State Obligations for CHIP Largely Unchanged

The Centers for Medicare & Medicaid Services’ (CMS) proposed rule (“Rule”) that updates Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems, leaves state obligations largely unchanged for the Children’s Health Insurance Program (“CHIP”).[1] Published on June 1, 2015, the proposed rule would codify statute and guidance that has … Continue Reading

CMS Seeks to Boost ACO Participation Through New Final Rule for MSSP

In line with its earlier announcement to tie increasing percentages of Medicare payments to quality and value through alternative payment models by 2018, the Centers for Medicare and Medicaid (CMS) released its final rule updating the Medicare Shared Savings Program (MSSP) and provisions relating to the payment of Accountable Care Organizations (ACOs) on June 4, … Continue Reading

Time is Running Out to Avoid the Negative Effects of 2016 Value-Based Physician Payment Modifiers: CMS Releases Results of Medicare’s Value-Based Payment Modifier for 2015 as Final PQRS Participation Deadlines for 2016 Adjustments Approach

CMS recently released results of Medicare’s value-based payment modifier for 2015.[1]  This is the first year in which physicians are subject to adjustments under the payment system and, in this first phase of implementation, only affects practices with 100 or more eligible professionals.  … Continue Reading

Medicare Advantage Insurers May See Positive Growth in 2016 Despite CMS’ 0.95% Payment Rate Cut Announcement

The Centers for Medicare and Medicaid Services (CMS) proposed a 0.95 percent decrease in Medicare Advantage payment rates for 2016 in its Advance Notice and Draft Call Letter released on February 20, 2015.[1] Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Unlike “original Medicare,” in … Continue Reading

HHS Launches New Payment and Delivery Model to Improve Oncology Care

Cancer care is notoriously complex, intensive and costly. With more than 1.6 million people diagnosed with cancer each year, there is a strong impetus towards reforming service delivery. Accordingly, the U.S. Department of Health and Human Services is launching a new payment and care delivery model for Medicare beneficiaries undergoing chemotherapy treatment.[1]… Continue Reading

CMS Defines “Uninsured” for Medicaid DSH Payments But Leaves Impact on Hospital-Specific Payments Undefined

CMS’ Final Rule, “Medicaid; Disproportionate Share Hospital Payments – Uninsured Definition”, published on December 3, 2014, may offer relief to some hospitals receiving Medicaid disproportionate share hospital (DSH) payments under the Social Security Act.[1] Starting December 31, 2014, the rule’s definition of “uninsured,” used to calculate the hospital-specific limitation on DSH payments, will allow for … Continue Reading

Final Meaningful Use Rule: CMS Loosens its Grip

The Centers for Medicare & Medicaid Services (“CMS”) finalized a rule on August 29th which should give providers some breathing room in complying with meaningful use requirements for the Electronic Health Record (“EHR”) Incentive Program (the “Final Rule”).  The EHR Incentive Program was developed by CMS to motivate health care providers to use and implement EHR … Continue Reading

The Future of DSH Payments?

According to the Centers for Medicare and Medicaid Services (CMS), the federal government disburses $11.5 billion annually in disproportionate-share hospital (DSH) payments to states.  DSH payments are intended to offset the cost of treating the uninsured (uncompensated care) and Medicaid shortfalls in public hospitals.  A recent study published in Health Affairs on the impact of … Continue Reading
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