Category Archives: Reimbursements

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CMS Continues to Tighten the Belt on Hospital Off-Campus Provider-Based Departments

hospital
Hospitals with off-campus provider-based departments (PBDs) may want to rethink their end of summer vacation plans in order to focus on a recent slate of proposed regulations from the Center for Medicare and Medicaid Services (CMS) that seek to rein in Medicare reimbursement for outpatient hospital services – including at excepted/grandfathered off-campus locations.… Continue reading this entry

When Is Compensation Unreasonable?

cardiologist
Just what is reasonable compensation in the Medicare world is not a clearly defined, black and white concept. Instead, it is somewhat in the eye of the beholder, with the parties to each situation where that is an issue seeking to reach out for third party support for their conclusions. But sometimes when the government … Continue reading this entry

340B: DC Circuit Affirms Dismissal of Challenge to 2018 Reimbursement Cuts for 340B Hospitals; New Cuts Already Being Proposed by CMS for 2019

On Tuesday, July 17, 2018, the United States Court of Appeals for the District of Columbia ended a challenge brought by hospitals and hospital associations to the nearly 28 percent reimbursement cuts for 340B hospitals under the Medicare program. The payment cuts were finalized in the calendar year (CY) 2018 Medicare Outpatient Prospective Payment System … Continue reading this entry

The Battle Over Drug Pricing: First Shot Targets Pharmacy Benefit Managers  

pharmacy
On July 18, 2018, the federal Department of Health and Human Services (HHS) sent a proposed rule to the Office of Management and Budget (OMB) for review and clearance. While the substance of the proposed rule is not yet published (or leaked), the title of the rule itself is rather transparent: Removal of Safe Harbor … Continue reading this entry

Loan or Other Financial Obligation Forgiveness– A Continuing Fraud and Abuse Challenge

There are many health care financial arrangements where one entity has a financial obligation to another, with whom it either does business directly, or to which it makes referrals, and that obligation is either past due or for one reason or another cannot be paid. This may come up, for example, in the context of … Continue reading this entry

CMS Recoupment Efforts Stopped by Court While Overpayment Appeals Are Pending

Overpayment
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 … Continue reading this entry

New Demonstration Program Would Reward Clinicians for Accepting Risk in Medicare Advantage

government building
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 … Continue reading this entry

Two Recent Examples of Challenges To Collect “Reasonable” Charges

Two recent cases illustrate the continuing challenges providers, and in particular hospital providers, face when seeking to collect their charges when dealing with “out-of-network” patients. First Example – A Claim for Services Under an ERISA Plan In the first, a not for publication decision of the 9th Circuit, Eden Surgical Center v. Cognizant Technology Solutions … Continue reading this entry

Direct Provider Contract Alternative Payment Model - CMS/CMMI Issues Request for Information

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On April 23, 2018, the Center for Medicare and Medicaid Innovation issued a Request for Information (the RFI) on a direct provider contracting model for primary care. The RFI seeks input on how direct provider contracting between the Centers for Medicare and Medicaid Services (CMS) and physicians or physician group practices may be designed and … Continue reading this entry

Medicare Enrollment for Providers No Longer Required Under Medicare Parts C and D

controlled substances
On April 2, 2018, CMS released the Contract Year 2019 Final Rules for Medicare Advantage (MA) and Part D (the MA Final Rule), incorporating changes that support CMS’ stated commitment to supporting flexibility and efficiency throughout the MA and Part D Programs.… Continue reading this entry

6 Key Takeaways for Providers on BPCI-Advanced (Value-Based Medicare Payment)

Policy
Despite some initial difficulty in gaining momentum, the use of value-based payment methodologies will likely increase across all provider niches. This change is partly a function of cost savings driven by margin compression (e.g. inpatient care) as well as by government payment models rewarding quality and efficiency, such as the Medicare Access and CHIP Reauthorization … Continue reading this entry

California Medicaid Agency Proposes Significant Restrictions on FQHC and RHC Reimbursement

california
California’s Medicaid agency has posted draft language of a new state plan amendment (SPA) that would make major changes to federally qualified health center (FQHC) and Rural Health Clinic (RHC) reimbursement.  Public comments may be made on the proposal until 5 PM on March 23, 2018.  Following review of public comments, the California Department of … Continue reading this entry

Telehealth Billing Compliance: Medicare Says Goodbye to the GT Modifier

medicaid
For over a decade, Medicare has required providers to append special modifiers to their CPT and HCPCS codes when billing for telehealth services. The two primary modifiers for telehealth services were GT (indicating the service was delivered via an interactive audio and video telecommunications system) and GQ (indicating the service was delivered via an asynchronous … Continue reading this entry

Medicare’s New Remote Patient Monitoring Reimbursement: What Providers Need to Know

The new year continues to offer big opportunities for telemedicine and digital health companies, and one of the most notable developments is CMS’ decision to reimburse providers for remote patient monitoring (RPM).  Effective January 1, 2018, the Medicare program will pay providers for RPM services billed under CPT code 99091.  The service is currently defined … Continue reading this entry

Court Rules Against 340B Hospitals, Allows Medicare Reimbursement Cuts to Go Forward

controlled substances
On Friday, December 29, 2017, the U.S. District Court for the District of Columbia dealt a blow to hospitals participating in the 340B Drug Pricing Program.  By participating in the 340B program, eligible public and not-for-profit hospitals receive significant discounts on the cost of acquiring outpatient prescription drugs.  The court ruled in favor of the … Continue reading this entry

CMS Finalizes Reimbursement Cuts for 340B Hospitals

hospital
In a striking blow to 340B hospitals, the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) released a final Medicare Outpatient Prospective Payment System (OPPS) rule adopting its earlier proposal to significantly reduce Medicare reimbursement for separately payable outpatient drugs purchased by hospitals under the 340B program.  The final rule … Continue reading this entry

Will the Massachusetts Proposed Legislation on Hospital Outpatient Facility Fees Have a Nationwide Impact?

hospital
In some states, including the Commonwealth of Massachusetts, “site neutrality” for outpatient hospital reimbursement is factoring into state-specific health reform and cost containment initiatives. This potentially goes well-beyond Medicare’s limitation of reimbursement at new off-campus outpatient hospital departments under Section 603 of the Bi-partisan Budget Act of 2015. Since Massachusetts’ state health reform law was … Continue reading this entry

Mandatory Cardiac Episode Payment Program: CMS Proposes Cancellation

hospital
Also Changes Required Participation in the CJR Model   On August 15, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule (Proposed Rule) that, if finalized, would (1) reduce the number of Metropolitan Statistical Areas (MSAs) in which there is mandatory participation in the Comprehensive Care Joint Replacement model (CJR) from … Continue reading this entry

Ninth Circuit Victory Opens the Door to Medicaid Reimbursement Challenges Based on Equal Access Requirement

reimbursements
The Ninth Circuit held August 7 that the Department of Health and Human Services Secretary erred in approving a Medicaid State Plan Amendment (SPA) that cut reimbursement for outpatient hospital services in California by 10% for eight months in 2008-2009. The Hoag Memorial decision sided with the 57 hospitals that challenged the SPA under the … Continue reading this entry

Medicare Claims Appeals: D.C. Circuit Reverses and Remands in Case Seeking Relief From Processing Delays

hospital
Summary of AHA v. Price, 2017 U.S. App. LEXIS 14887 (D.C. Cir. Aug. 11, 2017)   On August 11, 2017, the D.C. Circuit reversed the district court and held that the district court abused its discretion by ordering the Secretary of HHS to clear the backlog of administrative appeals of denied Medicare reimbursement claims within … Continue reading this entry

Proposed Rule Would Slash Medicare Payment for 340B Drugs

hospital
The Centers for Medicare and Medicaid Services (CMS) has proposed reducing the Medicare payment rate to hospitals for most separately payable drugs purchased under the 340B program from average sales price (ASP) plus six percent to ASP minus 22.5%.  This reimbursement cut — almost 30% in the aggregate— would significantly reduce the savings available to … Continue reading this entry

Proving Utility, Demonstrating Value: How to Align the Moving Parts in Personalized Medicine Reimbursement

Of the many business, operational, legal, regulatory and clinical obstacles standing in the way of widespread delivery of personalized medicine, the single greatest challenge may lie in solving the reimbursement puzzle. Advocates of personalized medicine contend that it results in better care for the patient, as therapy is targeted specific to an individual, and that … Continue reading this entry

HRSA Announces Final Rule on Civil Monetary Penalties for Drug Manufacturers that Overcharge 340B Covered Entities

A new regulation issued by the Health Resources and Services Administration (“HRSA”) sets forth a process by which civil monetary penalties may be imposed on drug manufacturers that knowingly and intentionally charge 340B covered entities for covered outpatient drugs more than the statutory ceiling price. The regulation addresses the ceiling price calculation for drugs purchased … Continue reading this entry

CMS Finalizes Mandatory Cardiac Care Bundled Payment Model and More

On December 20, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (the Final Rule) which includes three new mandatory episode-based payment programs for cardiac care, as well as the expansion of the Comprehensive Care for Joint Replacement Model (CJR). The models are implemented by the CMS Innovation Center, under authority … Continue reading this entry