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

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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

By Sheppard Mullin 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

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

Eric KleinRachel LandauerBy Eric Klein and Rachel Landauer on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicaid, Medicare
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

Vinay BhupathyBy Vinay Bhupathy on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicaid, Medicare
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

CMS Proposes to Modify—but Continues to Stand Behind—its “Two-Midnight” Rule

Vinay BhupathyRachel LandauerBy Vinay Bhupathy and Rachel Landauer on Posted in Centers for Medicare and Medicaid Services ("CMS")
The “Two-Midnight” rule is a Centers for Medicare and Medicaid Services (“CMS”) billing policy which bases the appropriateness of payments for inpatient services under Medicare Part A versus Part B on provider expectations regarding length of stay.  It has been a source of controversy since its inception in 2013.  In addition to receiving an extended … Continue Reading

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

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

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

There Is Potential Federal Inconsistency Over ACOs

David GarciaBy David Garcia on Posted in Accountable Care Organization (ACO), Centers for Medicare and Medicaid Services ("CMS")
On June 4, 2015, the Centers for Medicare & Medicaid Services issued final revisions to regulations governing accountable care organizations participating in the Medicare Shared Savings Program (“MSSP”). Among them is one explicitly requiring the formation of an ACO as a formal, separate legal entity for governance purposes whenever there are two or more ACO … Continue Reading

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

By Sheppard Mullin on Posted in Accountable Care Organization (ACO), Centers for Medicare and Medicaid Services ("CMS"), Medicaid
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

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

Vinay BhupathyBy Vinay Bhupathy on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare
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 ACO v. 3.0—More Risk, More Money?

Aytan DahukeyBy Aytan Dahukey on Posted in Accountable Care Organization (ACO), Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")
The Centers for Medicare and Medicaid (CMS) announced on March 10, 2015 that it is adding a new Accountable Care Organization (ACO) model to its cadre of innovative models.[1] Titled the “Next Generation ACO Model,” CMS’ new ACO model allows provider groups to assume higher levels of financial risk and reward than currently available under … Continue Reading

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

Vinay BhupathyBy Vinay Bhupathy on Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicaid, Medicare
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
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