Tag Archives: CMS

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

Christine ClementsErica KrausMichael PaddockBy Christine Clements, Erica Kraus and Michael Paddock on Posted in Medicare, Medicare Advantage
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

New DOJ Guidance Policy Limits Use of Guidance Documents in Federal Civil Actions

Matthew GoldmanJordan GrushkinCody FierroBy Matthew Goldman, Jordan Grushkin and Cody Fierro on Posted in Fraud and Abuse
[1] On January 25, 2018, Associate Attorney General Rachel Brand issued a memorandum on behalf of the U.S. Department of Justice (DOJ) (the “Brand Memo”) which effectively limits the use and enforcement power of guidance documents for the purposes of affirmative civil enforcement cases, a development that could have a significant impact on how certain … Continue Reading

340B Drug Pricing Program Litigation Update

Kenneth YoodMatthew GoldmanJordan GrushkinSamuel GilkesonBy Kenneth Yood, Matthew Goldman, Jordan Grushkin and Samuel Gilkeson on Posted in Hospitals, Medicaid, Medicare
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

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

Kenneth YoodMatthew GoldmanJordan GrushkinSamuel GilkesonBy Kenneth Yood, Matthew Goldman, Jordan Grushkin and Samuel Gilkeson on Posted in Hospitals, Medicaid, Medicare
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

MACRA Update: How to Prepare for Changes in MIPS

Kenneth YoodErica KrausMatthew GoldmanBy Kenneth Yood, Erica Kraus and Matthew Goldman on Posted in MACRA
As we reported last month, CMS’ proposed rule updating MACRA’s Quality Payment Program (“QPP”) for CY 2018 would extend and expand exceptions that would allow many practitioners to avoid participating in its Merit-based Incentive Payment System (“MIPS”) during next year’s performance period. In particular, the proposed rule would increase the low-volume threshold for MIPS-participation from … 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

MACRA Quality Payment Program Update

Kenneth YoodErica KrausMatthew GoldmanBy Kenneth Yood, Erica Kraus and Matthew Goldman on Posted in MACRA
On June 20, 2017, CMS released its proposed rule updating MACRA’s Quality Payment Program (“QPP”) for CY 2018. At over 1,000 pages, the rule might not do much to simplify the already complex requirements of the QPP; however, it would expand and extend the flexibility offered by CMS to practitioners in the 2017 performance period … Continue Reading

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

Steven ChananieSophie SolomonBy Steven Chananie and Sophie Solomon on Posted in Medicare
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

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 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
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