Tag Archives: Medicare

CMS Delays Implementation of New Payment Models (Again)

On March 21, 2017, the Centers for Medicare and Medicaid Services (“CMS”) published an interim final rule (“Interim Final Rule”) delaying (i) the effective date of several new Medicare payment models developed by the CMS Innovation Center to advance care coordination, and (ii) the implementation of updates to an additional existing model.… Continue Reading

CMS says to physicians: Pick your pace for MACRA implementation. Physicians say to CMS: Thank you for hearing us.

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued proposed regulations (Proposed Regs.) as a first step in the implementation of the Quality Payment Program (QPP) provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  In response to public comments regarding the Proposed Regs., CMS announced on September … Continue Reading

New Study Finds Medicare Advantage Plans Pay Lower Prices Than Traditional Medicare

A new study by Stanford University researchers finds that Medicare Advantage plans pay lower prices than traditional fee-for-service (FFS) Medicare for most types of hospital admissions. According to the study—published earlier this month in Health Affairs—Medicare Advantage plans pay hospitals about 8% less than FFS Medicare for the same services. These findings may come as … 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

Ambulatory Surgery Centers Finally Get Some Relief

By Aleah Yung On Saturday, September 22, 2012, Governor Brown signed SB 1095, which clarifies ambulatory surgery center (“ASC”) pharmacy licensure eligibility. This is great news for ASCs which have struggled since a controversial 2007 court decision had unintended consequences that effected the ability of ASCs to obtain pharmacy licenses.… Continue Reading

New Medicare Advantage Audits Likely to be Challenging for and Challenged by Providers and Plans

By Karie Rego Since the 2006 payment year, CMS has conducted Risk Adjustment Data Validation (RADV) audits on Medicare Advantage (MA) plans’ risk adjustment payments. However, CMS has been hindered by the lack of a methodology to extrapolate audit results. On February 23, 2012, CMS posted its final error calculation methodology. This methodology, if implemented, … Continue Reading

Medicare Issues Final Rule for the End-Stage Renal Disease Prospective Payment System

By Lynsey Mitchel The Centers for Medicare and Medicaid Services (“CMS”) released a final rule on November 1, 2011, that will update Medicare policies and payment rates for dialysis facilities. According to CMS these provisions will strengthen “incentives for improved quality of care and better outcomes for beneficiaries diagnosed with End-stage Renal Disease (“ESRD”). The … Continue Reading

Termination from Medicare and Medicaid Programs Due to Confusion Over Standards

By Karie Rego It is important for home health agencies and other providers that serve both Medicare and Medicaid populations to be aware of the differences in requirements. With the reductions in staffing, surveyors may be reviewing more than one program. We recommend a review of the different legal requirements and keeping information on hand … Continue Reading

Insurer to Purchase Vertically Integrated Medicare Advantage Plan/Provider

By Eric Klein and Aytan Dahukey WellPoint, one of the nation’s largest health insurers, has agreed to buy CareMore for approximately $800 million. WellPoint, which holds the license for Blue Cross in California and for Blue Cross Blue Shield in several other states, is the largest American health insurer in terms of patients covered, with one in … Continue Reading

Finding and Fixing Provider-Based Criteria Problems

By Karie Rego The Medicare provider based criteria have been around for over 10 years but still raise cause for concern. Basically on or off campus patient care locations that meet the criteria get to bill at higher hospital rates. Because the implications of not meeting the provider based rules are great (the assessment of … Continue Reading
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