Category Archives: Medicare

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More Than 700 CEOs of Hospitals and Health Systems Write to Congress to Stop Cuts to the 340B Drug Pricing Program

On October 2, 2018, the CEOs of more than 700 hospitals and health systems representing healthcare providers in all fifty states sent a letter to Congress (the “Letter”) in a collective effort to protect the 340B Drug Pricing Program (the “340B Program”).[1] The CEOs expressed their view that recent governmental actions have reduced the reach … Continue Reading

CMS’ Medicare Advantage Overpayment Rule: Arbitrary, Capricious, and Vacated

In a key case being watched by the industry, Judge Collyer of the United States District Court for the District of Columbia issued an opinion today granting UnitedHealthcare’s Motion for Summary Judgment in UnitedHealthcare Insurance Co. v. Azar, No. 16-157 (D.D.C.), which challenged CMS’ 2014 Overpayment Rule (the “Rule”). Judge Collyer’s decision vacated the Rule … Continue Reading

Reimbursement for and Documentation of Evaluation and Management Services: CMS Proposes Important Modifications

On July 12, 2018, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule (“Proposed Rule”) that would, among other changes: (1) reduce the documentation requirements with which physicians and other practitioners must comply in providing and billing for Evaluation and Management (E/M) services under the Medicare Physician Fee Schedule (“PFS”) on or … Continue Reading

340B Drug Pricing Program Litigation Update: American Hospital Association, Et Al. v. Azar

On July 17, 2018, the Court of Appeals for the D.C. Circuit upheld the D.C. District Court’s decision to dismiss the lawsuit led by the American Hospital Association, the Association of American Medical Colleges, and America’s Essential Hospitals challenging $1.6 billion in cuts to the 340B Drug Pricing Program. American Hospital Association, et al., v. Azar.… Continue Reading

Medicare Advantage to Address Social Determinants of Health: An Important Step for Value-Based Care

On April 4, 2018, the Centers for Medicare & Medicaid Services (“CMS”) finalized guidance and policies for the Medicare Advantage program that will expand the supplemental benefits afforded to beneficiaries to include items and services that address certain “social determinants of health” (“SDOH”). SDOH refers to a wide range of factors and conditions that are … Continue Reading

The Bipartisan Budget Act Boosts Medicare: Flexibility and Financing for Healthcare Plans and Providers

On Friday, February 9, 2018, President Trump signed the Bipartisan Budget Act of 2018 (the “Budget”), a two-year budget which, in significant part, made substantial revisions to Medicare, including the Medicare Advantage (MA) program. Such revisions include: i. the addition of non-medical services (e.g., home-delivered meals, transportation to and from a physician’s office, etc.) and telehealth … Continue Reading

Temporal Proximity Is Not Enough: Third Circuit Nixes FCA/Anti-Kickback Suit For Failure To Link Alleged Scheme to Claims

On January 19, 2018, the United States Court of Appeals for the Third Circuit affirmed a district court’s ruling granting summary judgment to a specialty pharmacy that was accused of violating the Anti-Kickback Statute and the federal False Claims Act (United States ex rel. Greenfield v. Medco Health Solutions, Inc. et al., No. 17-1152.). The … Continue Reading

Day 1 Notes from the 2018 JP Morgan Healthcare Conference in San Francisco

San Francisco (Monday, January 8, 2018): Outside it was raining heavily today in San Francisco, but inside the 2018 JP Morgan Healthcare Conference the weather was distinctly sunny. Nary a hint of gloom or pessimism was heard today from the hospitals and health plans presenting at the conference, even after the joys of last year’s … Continue Reading

‘Twas the Season to Contract? A Year-End Review of Network Negotiations and Billing Disputes

As 2017 drew to a close, some health plans and healthcare providers across the country were still busy trying to finalize contracts for in-network services for 2018 and beyond. A number of negotiations made the headlines in 2017, highlighting ongoing and emerging issues affecting network contracting. We recap for you some complex deals: in June, … Continue Reading

340B Drug Pricing Program Litigation Update

In November of last year, we wrote about a preliminary injunction being sought by hospital advocacy groups attempting to stop implementation of the Trump administration’s cuts to the 340B Drug Pricing Program (“340B Program”). Last week, the Motion for a Preliminary Injunction was denied and the case was dismissed in a final, appealable order. As … Continue Reading

President Trump Signs Tax Reform Bill Into Law

Today, President Trump signed into law a sweeping tax reform bill passed by the House and the Senate on Wednesday that will materially affect virtually every sector in the economy, including, perhaps to a greater degree than others, the healthcare sector. Between the bill’s repeal of the Affordable Care Act’s individual mandate penalty tax and … Continue Reading

MACRA Quality Payment Program Final Rule: Implications for 2018 and Beyond

On November 2, 2017, CMS published its final rule (the “Final Rule”) on the 2018 Quality Payment Program (“QPP”), authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”). This final rule adopted many of the proposals put forward by CMS in its June 2017 proposed rule, summarized here. But the final rule … Continue Reading

The 340B Drug Pricing Program: New CMS Final Rule Draws a Motion for Preliminary Injunction from Hospital Groups

On November 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the final rule, “Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs” (“Final Rule”). The Final Rule, in addition to the usual collection of annual Medicare payment updates and adjustments for the coming year, includes … Continue Reading

Alert: In a Surprise Decision Issued on October 5, 2017, Honorable John Walter, United States District Judge, Dismissed a Medicare Advantage Risk Adjustment Fraud Suit Against UnitedHealthcare

On October 5, 2017, the Honorable Judge John Walter of the United States District Court, Central District of California, granted the Defendants’ Motion to Dismiss the Medicare Advantage (“MA”) Federal False Claims Act (“FCA”) case of United States of America ex rel. Swoben v. Scan Health Plan, et al. (CV 09-5013-JFW (JEMx)) (the “Swoben Case”) … Continue Reading

CMS Aims to Nix Obama-Era Payment Models

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

The Enforcement Risks for Medicare Advantage Plans Continue: A New False Claims Act Settlement in Florida

Recent activities of the Department of Justice (“DOJ”) and Qui Tam whistleblowers reveal that Medicare Advantage Plans remain at the forefront of investigations for violations of the federal False Claim Act (“FCA”) for allegedly engaging in improper risk adjustment practices and other improper or fraudulent practices. In addition to the pending FCA enforcement cases in … Continue Reading

Medicare Advantage Plans Under Fire: The Department of Justice Files Complaints-in-Intervention

As reported in earlier blogs, the federal Department of Justice (DOJ) has been actively looking into potential abuses by Medicare Advantage (MA) Organizations as to allegedly improper risk adjustment claims submissions and practices. Earlier this month, and as had been anticipated, the DOJ filed complaints-in-intervention against UnitedHealth Group, Inc., and related Medicare Advantage entities, in … Continue Reading

The Opportunities and Challenges of Freestanding Emergency Departments

Following our blog post regarding the retail clinic movement, “Patient Check-Ups Before Checking Out: Partnering to Bring Health Care into the ‘One-Stop Shopping’ Sector” (April 19, 2017), we continue our examination of alternative healthcare providers by examining the regulatory landscape that shapes the opportunities and challenges of freestanding emergency departments (“FSEDs”).… Continue Reading

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

Food for Thought (and Health): Day 2 Notes from the JP Morgan Healthcare Conference

Addressing the Social Determinants of Health:  Is the healthcare industry pushing a rock up a hill?  We collectively are trying to provide healthcare with improved quality and reduced cost, but the structure of the nation’s healthcare system remains heavily siloed with the social determinants of health often falling wholly or partly outside the mandate and … 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
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