Tag Archives: Medicare

CMS’s Mandatory Radiation Oncology Payment Model: Negative Reactions in the Radiation Oncology Treatment Community

On July 10 2019, the Centers for Medicare & Medicaid Services (“CMS”) issued a Notice of Proposed Rulemaking (“NPR”) entitled, “Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures.” In the NPR, CMS proposes to implement two new mandatory specialty care payment models – one of which, the Radiation Oncology Model … Continue Reading

CMS Finalizes Rule Expanding its Authority to Deny and Revoke Medicare Program Enrollment, Among Other Changes

On September 5, 2019, the Centers for Medicare and Medicaid Services (“CMS”) released a final rule with comment period entitled, “Program Integrity Enhancements to the Provider Enrollment Process” (the “Final Rule”). The Final Rule, aiming to “address various program integrity issues and vulnerabilities by enabling CMS to take action against unqualified and potentially fraudulent entities … Continue Reading

Proposed and Expanded Disclosure Obligations for Hospitals Regarding not Only Gross Charges, but Third Party Payor Pricing as Well

On July 29, 2019, CMS released its proposed outpatient prospective payment system (“OPPS”) rule outlining a variety of changes it may implement for calendar year 2020. One proposal that has inspired immediate reactions from industry members would require hospitals to disclose certain additional pricing information, including some prices negotiated with third party payors, to the … Continue Reading

Is Prescription Drug Pricing The Cure For Partisanship?

In a rare act of bipartisanship, Senate Finance Committee Chairman Chuck Grassley, R-Iowa, and Ranking Member Ron Wyden, D-Ore., introduced on July 23rd a chairman’s mark, the Prescription Drug Pricing Reduction Act (PDPRA) of 2019 (the “PDPRA” or “Mark”), to lower the price of prescription drugs for Americans. According to the Committee, the Congressional Budget … Continue Reading

CMS Proposes New Home Health Agency Rule Including Potential Changes to Reimbursement, Coverage, Quality, and More: CMS Accepting Comments until September 9, 2019

On July 11, 2019, the Centers for Medicare and Medicaid Services (“CMS”) announced a proposed rule for home health agency Medicare reimbursement that would increase payments by an aggregate 1.3% for 2020, amounting to $250 million. In doing so, CMS would begin a transition to payments that are value-based, implementing the Patient-Driven Groupings Model (“PDGM”), … Continue Reading

CMS Proposes Changes to Medicare Wage Index that Would Increase Reimbursement Rates to Rural Hospitals at the Expense of Urban Hospitals

On May 3, 2019, the Centers for Medicare & Medicaid Services (“CMS”) published a comprehensive proposed rule (“Proposed Rule”) to revise the Medicare payment structure for inpatient prospective payment systems (“IPPS”) hospitals. According to the preamble of the Proposed Rule, the purpose of the Proposed Rule is to bump up Medicare’s reimbursements to rural hospitals, … Continue Reading

SCOTUS Rejects CMS DSH Policy, Calls CMS Guidance Practices Into Question

Earlier this week, the Supreme Court upheld a D.C. Circuit Court decision vacating a policy of the Centers for Medicare and Medicaid Services (“CMS”) that would have “dramatically – and retroactively – reduced payments to hospitals serving low-income patients.” Azar v. Allina Health Services, 587 U.S. __ at 1 (2019). The Supreme Court’s Allina opinion … 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

Take-Aways from CMS’ Recent Listening Session Regarding E/M Services: Documentation Guidelines and Burden Reduction

On March 21, 2018, a representative from the Hospital and Ambulatory Policy Group at the CMS, held a listening session regarding proposed updates to documentation guidelines for Evaluation and Management (“E/M”) Services. The purpose of this listening session was for the agency to obtain stakeholder feedback in order to develop policy proposals for upcoming notice … 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

Disproportionate Share Hospitals Facing Steep Payment Cuts

While September 30, 2017 has been an important procedural deadline for purposes of the GOP’s most recent legislative push to repeal the Affordable Care Act (ACA), it also serves a critical funding deadline for purposes of the Disproportionate Share Hospital (DSH) payment program. Absent legislative action, DSH payments are set to be reduced by $2 … 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

CMS Delays Implementation of New Payment Models (Again)

On March 21, 2017, the Centers for Medicare and Medicaid Services (“CMS”) published an interim final rule (“Interim Final Rule”) delaying (i) the effective date of several new Medicare payment models developed by the CMS Innovation Center to advance care coordination, and (ii) the implementation of updates to an additional existing model.… Continue Reading

CMS says to physicians: Pick your pace for MACRA implementation. Physicians say to CMS: Thank you for hearing us.

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

New Study Finds Medicare Advantage Plans Pay Lower Prices Than Traditional Medicare

A new study by Stanford University researchers finds that Medicare Advantage plans pay lower prices than traditional fee-for-service (FFS) Medicare for most types of hospital admissions. According to the study—published earlier this month in Health Affairs—Medicare Advantage plans pay hospitals about 8% less than FFS Medicare for the same services. These findings may come as … 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

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

Medicare Board of Trustees Releases 2016 Annual Report: Hospital Trust Fund Insolvency Projected by 2028

The Medicare Board of Trustees is calling for urgent legislative action to address the impending financial insolvency of the Medicare hospital benefit program. The Board’s 2016 report reveals the trust fund that pays for hospital services under Medicare Part A will be depleted by year 2028. At that time, the report indicates Medicare revenue will … Continue Reading

CMS 2017 Proposal Reduces Home Health Reimbursements by $180 Million

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

Ambulatory Surgery Centers Finally Get Some Relief

By Aleah Yung On Saturday, September 22, 2012, Governor Brown signed SB 1095, which clarifies ambulatory surgery center (“ASC”) pharmacy licensure eligibility. This is great news for ASCs which have struggled since a controversial 2007 court decision had unintended consequences that effected the ability of ASCs to obtain pharmacy licenses.… Continue Reading

New Medicare Advantage Audits Likely to be Challenging for and Challenged by Providers and Plans

By Karie Rego Since the 2006 payment year, CMS has conducted Risk Adjustment Data Validation (RADV) audits on Medicare Advantage (MA) plans’ risk adjustment payments. However, CMS has been hindered by the lack of a methodology to extrapolate audit results. On February 23, 2012, CMS posted its final error calculation methodology. This methodology, if implemented, … Continue Reading

Medicare Issues Final Rule for the End-Stage Renal Disease Prospective Payment System

By Lynsey Mitchel The Centers for Medicare and Medicaid Services (“CMS”) released a final rule on November 1, 2011, that will update Medicare policies and payment rates for dialysis facilities. According to CMS these provisions will strengthen “incentives for improved quality of care and better outcomes for beneficiaries diagnosed with End-stage Renal Disease (“ESRD”). The … Continue Reading

Termination from Medicare and Medicaid Programs Due to Confusion Over Standards

By Karie Rego It is important for home health agencies and other providers that serve both Medicare and Medicaid populations to be aware of the differences in requirements. With the reductions in staffing, surveyors may be reviewing more than one program. We recommend a review of the different legal requirements and keeping information on hand … Continue Reading

Insurer to Purchase Vertically Integrated Medicare Advantage Plan/Provider

By Eric Klein and Aytan Dahukey WellPoint, one of the nation’s largest health insurers, has agreed to buy CareMore for approximately $800 million. WellPoint, which holds the license for Blue Cross in California and for Blue Cross Blue Shield in several other states, is the largest American health insurer in terms of patients covered, with one in … Continue Reading
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