Category Archives: Reimbursements

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

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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

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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

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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

21st Century Cures Act Provides Some Welcome Relief

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The 21st Century Cures Act (the “Cures Act”) (Pub. L. No. 114-255), which was signed into law by President Obama on December 13, 2016, includes a number of important health care provisions, and several address the long-anticipated relief for Medicare “site-neutrality” policies relating to off-campus outpatient hospital departments (“OCODPs”), certain cancer hospitals, and long-term care … Continue reading this entry

10 Things You Need to Know About Health Care Bankruptcies in 2017

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The coming year will likely continue to be a tumultuous year for health care providers, suppliers, and payers, as they adapt to meet new challenges and market forces, particularly in light of the open questions as to the viability and continued existence of the Affordable Care Act (ACA) and recent comments made by members of … Continue reading this entry

OPPS Final Rule Finalizes Limits for Off Campus Departments

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Center for Medicare and Medicaid Services (CMS) issued the long-awaited implementation of the “site-neutrality” provisions of the H.R. 1314 Bipartisan Budget Act of 2015 (BiBA Section 603) on November 1, 2016. The Final Rule will cause new (non-grandfathered) hospital off-campus outpatient departments to no longer be reimbursed under the Medicare Outpatient Prospective Payment System (OPPS). … Continue reading this entry

HRSA Proposes Administrative Process to Resolve Disputes Between 340B Program Covered Entities and Drug Manufacturers

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Taking a step toward completing a requirement imposed by the Affordable Care Act, the federal government has proposed regulations that would create an administrative dispute resolution (“ADR”) process to resolve disputes between 340B Program covered entities and drug manufacturers. As proposed, the ADR process would be available for covered entities to submit claims that they have … Continue reading this entry

CMS Proposes New Medicare Telehealth Coding Rules

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The Centers for Medicare and Medicaid Services (CMS) issued its proposed Medicare Physician Fee Schedule (PFS) for CY 2017 on July 7, 2016. In it, CMS would require practitioners to use a new place of service (POS) code to report telehealth services. The proposed rule also includes several new covered telehealth services. If enacted, the proposed rules are … Continue reading this entry

Rhode Island’s New Law Requires Health Plans Cover Telemedicine Services

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Rhode Island marks the 31st state to enact a telemedicine commercial reimbursement statute. The Telemedicine Coverage Act (HB 7160B) was signed into law by Rhode Island Governor Gina Raimondo on June 28, 2016, representing a forward step for telehealth providers in a state that historically has held one of the lowest-rankings in the nation for telehealth … Continue reading this entry

“Site Neutrality” for Off-Campus Outpatient Departments: Proposed Rule is Worse than You Expected!

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Please note, Cheryl Storey, CPA with Moss Adams LLP is also a co-author of this post. CMS issued its Outpatient Prospective Payment System (“OPPS”) Proposed Rule for 2017 (the “Proposed Rule”) on July 6, 2016. The Proposed Rule will  be published in the Federal Register on July 14, 2016. One highly-anticipated section of the Proposed Rule … Continue reading this entry

CMS Issues Final Rule on ACOs Participating in the Medicare Shared Savings Program

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The Centers for Medicare & Medicaid Services (“CMS”) issued a final rule (the “Final Rule”) for accountable care organizations (“ACOs”) participating in the Medicare Shared Savings Program (“MSSP”) on June 6, 2016. In the Final Rule, CMS reflects its continuing efforts to modify alternative payment programs to make them more workable while also moving toward … Continue reading this entry

New York Legislation to Require Payment Parity for Telehealth Services

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New York introduced a new bill designed to ensure commercial health plans pay for telehealth services at the same rate the plans pay for in-person services. The legislation, SB 7953, comes on the heels of New York’s long-awaited telehealth coverage law and seeks to add payment parity language to the State’s existing telehealth coverage statute. See … Continue reading this entry

Legislation to Expand Definition of Grandfathered Off-Campus Hospital Departments to Address “Mid-Build” and Cancer Hospital Projects Moves Forward

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A bill amending the “site neutrality” limitations brought by Section 603 of the Bipartisan Budget Act of 2015 was introduced in the House of Representatives last week and passed out of committee yesterday. H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016,” was introduced by two powerful Members of the House Ways and … Continue reading this entry

Recent New York Medicaid Settlement with Pharmacy Shows Importance of Checking Excluded Provider List Prior to Filling Prescriptions

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A New York pharmacy has agreed to pay approximately $500,000 to the State of New York for improperly billing New York Medicaid for prescriptions written by a physician who had been excluded from the Medicaid program. This settlement serves as an important reminder to all pharmacies operating in New York: Before filling a prescription, pharmacies … Continue reading this entry

CMS Abandons Payment Cut Imposed By Two-Midnight Rule

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In the Fiscal Year (FY) 2014 Inpatient Prospective Payment System (IPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) revised its Medicare policy for determining whether hospital encounters will be considered appropriately inpatient or outpatient. The status distinction has important consequences for both the provider and the beneficiary, including differences in co-insurance and … Continue reading this entry

CMS Announces Latest Alternative Payment Model - Comprehensive Primary Care Plus

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Continuing in its efforts to promote alternative payment models, on April 11, 2016, CMS announced the Comprehensive Primary Care Plus (CPC+) model. CMS hopes to implement CPC+ in up to 20 regions, accommodating up to 5,000 practices, which would potentially encompass more than 20,000 doctors and clinicians and the 25 million people they serve. The … Continue reading this entry

At The Intersection of New Bundled Payment Programs and New Discharge Rules: Private Equity Opportunities

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Recently, CMS has promulgated new bundled payment rules for Comprehensive Joint Replacement (CJR) that require the mandatory participation of approximately 800 hospitals across the US. This bundle includes not only the inpatient DRG care, but also 90 days of post-discharge care. Contemporaneously, CMS has initiated rulemaking which totally revamps the discharge planning process for hospitals by requiring … Continue reading this entry

Florida Passes New Telehealth Bill: Focus is Reimbursement

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After several hard-fought years of unsuccessful attempts, the Florida Legislature on Friday passed a new bill designed to set the stage for telehealth commercial insurance coverage in the Sunshine State. This is a great step forward for providers of telehealth services, as the bill will result in a formal report to the Governor and Legislature … Continue reading this entry

CMS Proposed Rule Reduces Drug Payments & Requires Implementation of Value-Based Purchasing Tools

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Proposed Rule Recently, CMS published a Proposed Rule seeking to test a new model for how Medicare pays for drugs and biologicals paid under the Medicare Part B program. With the goals of determining whether alternative drug payment models will result in “better care” and “smarter spending” by reducing Medicare expenditures while enhancing the quality … Continue reading this entry

Comprehensive Joint Replacement Bundled Payment Program Begins April 1st

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Approximately 800 hospitals in 67 Metropolitan Statistical Areas will begin mandatory participation in the Comprehensive Care for Joint Replacement (CJR) Model on April 1, 2016. The CJR bundled payment program applies to MS-DRG 469 (major joint replacement or reattachment of lower extremity with major complications or comorbidities) and MS-DRG 470 (major joint replacement or reattachment … Continue reading this entry

Medicare Payments for Telehealth Increased 25% in 2015: What You Need to Know

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More good news on the telehealth reimbursement front: CMS reported its total 2015 payments for telehealth services under the Medicare program and it was a 25% increase over last year. This reflects how providers are successfully integrating telehealth services into their traditional health care delivery approaches, and are better realizing payment opportunities both within the … Continue reading this entry

Illinois Telemedicine Rules: Licensing, Practice, Payment

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Illinois is experiencing growth in telemedicine and telehealth offerings available to patients in the Prairie State. Historically, Illinois telehealth services have been more limited to hospital and institutional settings, but the last few years have since seen an expansion among providers offering such services directly to patients. And yet, Illinois remains a state that has … Continue reading this entry

340B Program Update

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The new year has already gotten off to a busy start for health care providers that participate in the 340B Drug Pricing Program (“340B Program”) and government agencies that reimburse these providers. Following on the heels of the publication of a Medicaid Covered Outpatient Drug Final Rule (“Final Rule”), the Centers for Medicare and Medicaid … Continue reading this entry

The Who, What, and When for the CMS Final 60-Day Rule

Four years after the issuance of the Proposed Rule and six years after the authorizing statute, CMS has published the much-awaited Final Rule regarding reporting and returning of Medicare Part A and B overpayments (the “Final Rule”). 81 Fed. Reg. 7654-7684 (Feb. 12, 2016).  Since the inception of section 6402(a) of the Affordable Care Act … Continue reading this entry