Category Archives: Centers for Medicare and Medicaid Services (“CMS”)

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CMS Pushes for Hospital Price Transparency in Proposed Rule

Matthew GoldmanJordan GrushkinCody FierroBy Matthew Goldman, Jordan Grushkin and Cody Fierro on Posted in Centers for Medicare and Medicaid Services ("CMS")
On April 24, 2018, the Centers for Medicare & Medicaid Services (“CMS”) announced a new proposed rule (CMS-1694-P) (“Proposed Rule”). In an attempt to “empower patients through better access to hospital price information,” CMS plans to alter the requirements previously established by Section 2718(e) of the Affordable Care Act.[1] Under Section 2718(e), “each hospital operating … Continue Reading

CMS Proposes “Wind Down” Plan for Federal Exchanges

Cody FierroMatthew GoldmanJordan GrushkinBy Cody Fierro, Matthew Goldman and Jordan Grushkin on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
Despite the Trump Administration’s unsuccessful attempts to fully repeal and replace the Affordable Care Act (the “ACA”), the Administration has continued to target the ACA. In the Administration’s latest salvo, the Centers for Medicare & Medicaid Services (“CMS”) announced in its Fiscal Year 2019 Performance Budget (the “Budget”)[1] – as released by the federal Office … Continue Reading

Take-Aways from CMS’ Recent Listening Session Regarding E/M Services: Documentation Guidelines and Burden Reduction

Lynsey MitchelBy Sheppard Mullin and Lynsey Mitchel on Posted in Centers for Medicare and Medicaid Services ("CMS")
On March 21, 2018, a representative from the Hospital and Ambulatory Policy Group at the CMS, held a listening session regarding proposed updates to documentation guidelines for Evaluation and Management (“E/M”) Services. The purpose of this listening session was for the agency to obtain stakeholder feedback in order to develop policy proposals for upcoming notice … Continue Reading

CMS Aims to Nix Obama-Era Payment Models

Aytan DahukeyMatthew GoldmanJordan GrushkinBy Aytan Dahukey, Matthew Goldman and Jordan Grushkin on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare
In a proposed rule published Tuesday, August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) announced its intention to roll back a handful of payment models introduced under the Obama Administration. If implemented, the rule would cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) Incentive Payment Model, each currently set to … Continue Reading

CMS Delays Implementation of New Payment Models (Again)

Kenneth YoodRachel LandauerBy Kenneth Yood and Rachel Landauer on Posted in Centers for Medicare and Medicaid Services ("CMS")
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

Medicaid Demonstration Waivers: A Shorter Path to Increasing State Control Over Healthcare Policy?

Steven ChananieRachel LandauerBy Steven Chananie and Rachel Landauer on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
Seema Verma’s nomination to head the Centers for Medicare and Medicaid Services (CMS) places Section 1115 Medicaid demonstration waivers into increasing spotlight. This article explores some of the current applications of waiver authority and the role it may play in the new administration.… Continue Reading

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

Kenneth YoodBy Kenneth Yood and Katherine Fragoso on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicaid, Medicare
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

The MACRA Final Rule: The Art of the Transition

Kenneth YoodErica KrausBy Kenneth Yood and Erica Kraus on Posted in Centers for Medicare and Medicaid Services ("CMS"), MACRA, Medicare
On Friday, October 14, 2016, CMS released the much-anticipated final rule (the “Final Rule”) implementing the Quality Payment Program (QPP), mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  Pursuant to MACRA and the Final Rule, most clinicians will be required to participate in either a new Merit-based Incentive Payment System (MIPS) … Continue Reading

Vermont to Launch a First-in-the-Nation All-Payer System for All Healthcare Providers

Kenneth YoodBy Kenneth Yood on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
As recently reported by Modern Healthcare and other major healthcare news outlets, the Obama administration has granted tentative approval for Vermont to establish an all-payer reimbursement system. If granted final approval, the Vermont All Payer Accountable Care Organization Model (Model) would be effective for five years from January 1, 2017 to December 31, 2022. The … Continue Reading

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

Kenneth YoodBy Kenneth Yood on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare
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

CMS Releases 2017 Medicare Hospital Payment Rates, Penalties for Poor Performers

Kenneth YoodBy Kenneth Yood and Katherine Fragoso on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare
Earlier this month, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (Final Rule) modifying the Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year (FY) 2017. CMS pays acute-care hospitals for services provided to Medicare beneficiaries under the IPPS and … Continue Reading

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

Eric KleinBy Eric Klein and Katherine Fragoso on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare, Medicare Access
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 Oncology Care Model Reforming Payment for Beneficiaries with Cancer

Lynsey MitchelBy Lynsey Mitchel on Posted in Centers for Medicare and Medicaid Services ("CMS")
The Center for Medicare & Medicaid Innovation first introduced its Oncology Care Model (OCM) last year. OCM went into effect July 1, 2016, and will run through June 30, 2021. The new multi-payer model is the first CMS physician-led care model aimed at improving cancer treatment for Medicare beneficiaries. CMS hopes to see improvements in … Continue Reading

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

Steven ChananieMichael McKinnonLinda IgarashiErica KrausBy Steven Chananie, Michael McKinnon, Linda Igarashi and Erica Kraus on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS"), False Claims Act, Medicaid, Medicare
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

Kristi KungBy Kristi Kung on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare
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

CMS 2017 Proposal Reduces Home Health Reimbursements by $180 Million

Lynsey MitchelBy Lynsey Mitchel on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS"), Medicare
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

Maryland Co-Op Claims Risk Adjustment Formula Discriminates Against Smaller Insurers

Eric KleinBy Eric Klein on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
Maryland’s Evergreen Health Cooperative has filed for an injunction against the federal government to halt payment by the  Consumer Operated and Oriented Plan (co-op) of the $22 million it owes to CareFirst BlueCross BlueShield based on the Affordable Care Act’s risk adjustment formula.  Of the 23 co-ops that launched in 2014, at least half of … Continue Reading

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

By Sheppard Mullin on Posted in Accountable Care Organization (ACO), Centers for Medicare and Medicaid Services ("CMS"), Medicare
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 Redefines Alternative Payment Models and Offers Option for Merit-Based Incentive Payment System in New Proposed Rule

Lynsey MitchelBy Lynsey Mitchel on Posted in Centers for Medicare and Medicaid Services ("CMS"), Healthcare Reform, Medicare Access
The Medicare Access and CHIP Reauthorization Act (MACRA) is expected to drastically change how physicians are paid by the Centers for Medicare and Medicaid Services (CMS). Under the proposed rule, physicians will be given the choice between two payment models: alternative payment models (APMs) and the Merit-Based Incentive Payment System (MIPS).  CMS predicts a majority … Continue Reading

New Amendments Grant Failing ACA Co-Op Program Access to Private Capital and Limit Special Enrollment Eligibility

Lynsey MitchelBy Lynsey Mitchel and Katherine Fragoso on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
Earlier this month, the Centers for Medicare and Medicaid Services (CMS) passed an interim final rule that amends regulations governing Consumer Operated and Oriented Plans (Co-ops) and tightens restrictions on special enrollment period (SEP) eligibility in the Health Insurance Marketplace. Of the 23 co-op plans established through the Affordable Care Act (ACA), only 11 are … Continue Reading

CMS Grants Extension to Apply for 2015 Meaningful Use Hardship Exemption

By Sheppard Mullin on Posted in Centers for Medicare and Medicaid Services ("CMS"), Healthcare Information Technology, Medicaid, Medicare
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

Matthew TuretzkyBy Matthew Turetzky on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS"), Medicaid, Medicare
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
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