Providers and suppliers who have been assessed overpayments for Medicare services are entitled, by statute, to a stay of recoupment while the provider or supplier’s appeal is pending – but only at the first two levels of administrative appeal. If both appeals are unfavorable to the provider or supplier, the next step is an appeal to the Office of Medicare Hearings and Appeals, where the matter is heard by an Administrative Law Judge (ALJ). During the now lengthy waiting time for the ALJ hearing, Medicare will recoup the overpayment by withholding current payments until the overpayment and interest are fully recovered. As might be imagined, this elimination of Medicare cash flow results in extreme financial hardship for the provider or supplier before it can have its appeal heard.
The Centers for Medicare and Medicaid Services just issued a proposed rule introducing monumental changes to the physician fee schedule, paving the way for asynchronous telemedicine and new technologies through a new set of virtual care codes. CMS explained the impetus for the bold changes, declaring:
“We now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology. From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago.”
Foley & Lardner LLP’s (“Foley”) Bipartisan Public Policy Team is pleased to share our “Public Policy Weekly* Health Care Newsletter” in which we compile the latest Health Care policy news and legislation. *Please note that we publish this newsletter only when Congress is in session.
CMS recently announced that it wants to launch a new demonstration program, the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration. If approved and adopted as a demonstration project, the MAQI Demonstration would waive Merit-Based Incentive Payment System (MIPS) requirements for clinicians who participate sufficiently in qualifying risk programs of Medicare Advantage plans by making such programs qualify for the Advanced Alternative Payment Model (AAPM) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA replaced the prior Medicare reimbursement schedule with a new pay-for-performance program that’s focused on quality, value, and accountability.
Earlier this month, the Department of Labor (DOL) released its Final Rule seeking to expand the scope of participation in Association Health Plans. The Final Rule, titled “Definition of ‘Employer’ under Section 3(5) of ERISA – Association Health Plans”, with a few revisions, codified the Proposed Rule. At its heart is a change to the criteria under ERISA under which employers may join together and be treated as the “employer” sponsor of a single multiple-employer benefit or group health plan under ERISA. This blog post provides an overview of the specifics of that change, and the potential opportunities that may result from the Final Rule.