Category Archives: Medicare

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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 Proposes to Limit Site Neutral Payment Exceptions Applicable to Certain Off-Campus Hospital Departments Following Relocation, Service Expansion, or Certain Ownership Changes

On July 6, 2016, CMS released the 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule which, among other things, implements Section 603 of the Bipartisan Budget Act of 2015.  Despite extensive lobbying efforts by the hospital industry, CMS’ proposed rule would effectively preclude the relocation or the expansion of service lines of existing off-campus provider-based … Continue Reading

Medicare Board of Trustees Releases 2016 Annual Report: Hospital Trust Fund Insolvency Projected by 2028

The Medicare Board of Trustees is calling for urgent legislative action to address the impending financial insolvency of the Medicare hospital benefit program. The Board’s 2016 report reveals the trust fund that pays for hospital services under Medicare Part A will be depleted by year 2028. At that time, the report indicates Medicare revenue will … Continue Reading

CMS 2017 Proposal Reduces Home Health Reimbursements by $180 Million

On June 27, CMS issued a proposal for the 2017 Medicare home health prospective payment system (HH PPS). CMS is proposing a $180 million reduction in 2017. This equates to a 1% drop in reimbursements for home health agencies caring for Medicare beneficiaries. This cut is the next in a series of reductions mandated by … Continue Reading

Medicare Makes Changes to the Shared Savings Program to Strengthen Incentives for ACO Care Coordination

On June 6th, the Centers for Medicare & Medicaid Services (CMS) released a final rule shifting how Medicare pays Accountable Care Organizations (ACO) in the Medicare Shared Savings Program.  CMS said the final rule aims to help more ACOs participate in the Medicare Shared Savings Program by improving the payment methodology and providing them with … 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

Congress Repeals Sustainable Growth Rate Formula and Advances Medicare Payment for Quality

On April 14, 2015, Congress ended over a decade of repeated “doc fixes” which temporarily suspended scheduled Medicare provider reimbursement cuts, by passing the Medicare Access and CHIP Reauthorization Act (the “Act”).  If signed by President Obama, the Act would permanently end the Centers for Medicare & Medicaid Services’ (“CMS”) use of the physician payment … 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

Task Force of Healthcare Providers and Insurers are Shifting to Incentive Based Contracts

Some of the largest healthcare providers and insurers in the country have joined to form the Healthcare Transformation Task Force in an effort to change healthcare industry payment models.  The announcement of the task force and its efforts come shortly after the Department of Health and Human Services announced plans to overhaul Medicare’s fee-for-service program … Continue Reading

HHS Aims to Tie Most Medicare Reimbursements to Quality by 2018

On January 26, 2015, Health and Human Services (HHS) Secretary Sylvia M. Burwell announced specific goals and a timeline for shifting Medicare reimbursements from the traditional fee-for-service (FFS) model, to a quality or value-based model.[1] This is the first time in Medicare’s history that HHS is setting specific goals for such a shift. Secretary Burwell … Continue Reading

Effects of the New Federal Spending Package on the Health Sector

In mid-December, President Obama signed into law a $1.1 trillion spending bill known as the “Consolidated and Further Continuing Appropriations Act, 2015” or “Cromnibus.”[1] This post explores provisions that relate to the health sector and Affordable Care Act (ACA) implementation.… 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

A (Second) Lawsuit Seeks to Compel Statutory Timeframe for Administrative Law Judge Review of Medicare Claims Appeals

On August 26th, the Center for Medicare Advocacy filed a nationwide class action lawsuit against the Secretary of Health and Human Services. The complaint alleges that, as implemented, the Medicare administrative review process is in violation of Medicare statutory obligations and the Fifth Amendment’s Due Process Clause.[1]… Continue Reading

$95 Billion Savings for Medicare – A New Forecast?

The New York Times in an August 27, 2014 article noted big changes to estimated Medicare spending in the latest Congressional Budget Office (CBO) report published last week.  The estimated Medicare budget for 2019 in this year’s report has declined by approximately $95 billion from the 2019 Medicare estimate published by the CBO four years … Continue Reading

Quantifying and addressing improper payments for Medicare evaluation and management services

A review of Medicare Part B claims for evaluation and management (E/M) services conducted by the Office of the Inspector General (OIG) has found that the program paid $6.7 billion in improper payments in 2010.[1] This figure represents 21 percent of all E/M payments for the year; E/M payments, generally, accounted for nearly 30 percent … Continue Reading

The push for greater transparency in healthcare continues

Recently, CMS released the proposed fiscal year 2015 Inpatient Prospective Payment System (IPPS) rule for inpatient stays in long-term and general acute care hospitals.[1] Included among the regular updates to Medicare payment policies and rates are guidelines for compliance with the Affordable Care Act’s hospital charges transparency requirement.… Continue Reading

Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015.  Medicare Recovery Audit Contractors (RACs) are prohibited from auditing inpatient hospital claims for compliance with the rule from October 1, 2013, through March 31, … Continue Reading
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