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Brian Daucher specializes in business litigation with emphasis on contract, healthcare, and intellectual property disputes.

Hospice providers within regions administered by NGS are reporting that NGS is presently finalizing and serving out final 2019 hospice cap repayment demands.  This action, which tacks on sequestration (funds never received) to revenue, is entirely inappropriate and must be rescinded.
Continue Reading CMS Sending Hospice Cap Demands Ahead of Schedule

On August 6, 2019, CMS finalized its 2020 hospice rule, including adopting, without substantial modification, two controversial and material changes to the hospice benefit:

  • Rebasing payment rates to shift about $500 million from routine care to enhanced levels of care including general inpatient, continuous, and respite care.
  • Adopting a requirement that, upon request (either at admission or later), hospices disclose in an extensive written addendum to patients (and other health care providers) any care that would be deemed unrelated to hospice care.

We reviewed these proposals in detail in prior blogs posts on rebasing and unrelated care disclosures; and, we submitted these comments to CMS.  In this blog, we will note the changes that CMS did make to these proposals and note some of the potential effects.


Continue Reading CMS Finalizes 2020 Hospice Rule: Big Changes Coming

Though beloved as a service, hospice can be a difficult subject for patients, families, and even caregivers. The recent short filmEnd Game (2018 NetFlix), follows a set of patients, families, and their caregivers through the difficult discussions and choices faced at end of life. It may help facilitate difficult discussions.
Continue Reading Hospice Short Film End Game Up For Academy Award

(as first posted in the Hospice Log Blog on April 12, 2018)

This year CMS is rolling out two new programs aimed, finally, at helping to settle certain types of pending provider reimbursement appeals. The programs are the Low Volume Appeals Initiative and Settlement Conference Facilitation.

As pointed out on the Hospice Law Blog before, CMS’ longstanding policy of refusing to negotiate overpayment findings has been a significant factor in clogging the appeals system. With no settlement options, each case must be decided on its merits, imposing a huge (indeed unmanageable) burden on the appeals system.
Continue Reading CMS Rolls Out Provider Appeals Settlement Efforts

Historically, health plans and pharmacy benefit managers (“PBMs”) have been uncomfortable neighbors. Plans provide drug coverage, but contract out the provision of such drugs to independent PBMs. PBMs in turn earn market rents by negotiating discounts (and big rebates) with Big Pharma, in turn offering structured medication formularies to plans.
Continue Reading Health Plans and Pharmacy Benefit Managers – Past and Future

Traditionally, the cap accounting year has ended October 31, putting the cap accounting year one month off of the Federal government fiscal year.   In May 2015, CMS proposed to adjust the cap accounting year to end September 30 to align with the Federal government fiscal year.  This transition will occur in 2017.

To change the accounting year, CMS will cut short the 2017 cap year, assessing cap for the 2017 cap year across only 11 months from November 2016 through September 2017.


Continue Reading Hospice Cap Calculation Changes

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present). In this post, Sheppard Mullin examines the recovery process CMS has put in place, noting CMS procedural shortcomings and reviewing some substantive defenses available to providers facing such demands.
Continue Reading A Review of CMS’ Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present Beneficiaries