On August 14, 2023, the Centers for Medicare & Medicaid Services (CMS) released guidance on changes to the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model starting in performance year 2024 (PY2024). The changes came about in response to stakeholder and participant feedback. All ACO REACH participants should familiarize themselves with the upcoming changes.
The intersection of patient satisfaction and quality of care is central to healthcare today, and a provider’s level of cultural competence can significantly impact his/her performance in both areas. Recent focus on diversity, equity, and inclusion initiatives in healthcare has impacted how policymakers are approaching related issues, such as cultural competence in patient care.[1] Some state governments have determined that a provider’s ability to deliver culturally competent care is an essential component to promoting effective and efficient healthcare delivery.[2] For example, Nevada, Oregon, Connecticut, New Jersey, California, Washington, New Mexico, and the District of Columbia each require some form of cultural competency training in their continuing education requirements for certain healthcare providers. In 2023, Illinois legislators introduced two major bills that mandate cultural competency training: H.B. 2450 and S.B. 2427. While these bills take different approaches, both seek to reduce challenges that patients can face in navigating the healthcare system in the absence of culturally competent care and well-resourced providers, including discrimination, reduced quality of services and insurance inadequacies.
On July 13, 2023, the Centers for Medicare & Medicaid Services (“CMS”) issued its proposed rule (the “Proposed Rule”) for the 2024 Medicare Physician Fee Schedule (“PFS”). The Proposed Rule, which was issued in the Federal Register on August 7, 2023, includes updated payment rates, changes to reimbursement for services related to health equity and social determinants of health, increases to payment for cancer care support, and changes to enrollment for mental health providers. CMS projects that the Proposed Rule will lead to growth in the Medicare Shared Savings Program (“MSSP”).
Continue Reading CMS Announces Proposed Rule for 2024 Medicare Physician Fee Schedule
Yesterday, the Supreme Court issued a unanimous decision holding that the scienter element of the False Claims Act (“FCA”) is met if a defendant subjectively knew his or her claims were false and submitted them anyway. See United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway. The Court’s ruling was narrow and avoided the more challenging—and common—issues raised during oral argument (which we previously discussed here).
While government enforcement has traditionally been an indirect concern for private equity (“PE”) investors, such as looking at whether a target entity has been sanctioned or could be sanctioned in the future, the current trend in government enforcement has been to target PE firms directly.
On January 30, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). CMS promotes the Final Rule as improving program integrity and payment accuracy as well as transparency and certainty. One thing that is certain, CMS can expect further challenges to its RADV audit methodology.
Continue Reading CMS Issues Long-Awaited Medicare Advantage RADV Final Rule
CMS announced today a further extension until February 1, 2023, of the deadline for its publication of the long-awaited final rule on the use of extrapolation and the application of a fee-for-service adjuster (FFS Adjuster) in risk adjustment data validation (RADV) audits of Medicare Advantage organizations (MAOs).
Late last month, the Biden Administration announced the second installment of its recovery plan, dubbed the “American Jobs Plan” (the “Plan”). The Plan’s $2.3 trillion price tag includes
Continue Reading The American Jobs Plan and the American Rescue Plan: The Biden Administration Bets Big on Home and Community-Based Services
On February 4, 2021, the Department of Justice (“DOJ”), Office of Public Affairs, issued a Press Release (the “DOJ Press Release”) announcing that Kelly Wolfe, President of Regency, Inc., a medical billing company located in Florida, pleaded guilty to conspiracy to commit healthcare fraud through a “pernicious telefraud scheme”[1] involving fraudulent Medicare and CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) claims for medically unnecessary durable medical equipment (“DME”) supplies. As a result of Wolfe’s criminal plea, Wolfe could face up to 13 years in federal prison.
Continue Reading OIG Warns Telehealth Industry: “With Great Power Comes Great Responsibility”
Telehealth services and providers have been in high demand as the world copes with the COVID-19 public health emergency. Federal and state agencies have amended, and often loosened, regulations in an attempt to facilitate and expand access to telehealth. However, the honeymoon phase of relaxed oversight may be coming to an end as the world adjusts to a new-normal.
Continue Reading The Honeymoon Phase Is Over: OIG to Audit COVID-19 Part B Telehealth Services
In response to the ongoing COVID-19 public health emergency (the “PHE”) first declared on March 13, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued blanket Section 1135 Waivers to expand, albeit on a temporary basis during the PHE, the range of healthcare professionals who can provide Medicare-covered telehealth services to include physical therapists, occupational therapists, speech language pathologists, and other non-physician practitioners. (See also, CMS Fact Sheet, “Medicare Telemedicine Health Care Provider Fact Sheet” (March 17, 2020) and CMS’s “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers” (December 1, 2020)).
Continue Reading The Other Shoe Drops: OIG To Audit COVID-19 Telehealth Home Health Services