Tag Archives: Medicare

DOJ and OIG Focus on Opioid Abuse: Medical Professionals Who Overprescribe May Be Targets

Two recent announcements reflect that the U.S. Government is taking aggressive steps to address opioid abuse by identifying and targeting the involvement of medical professionals in facilitating opioid abuse involving Federal health care program beneficiaries.  The U.S. Department of Justice announced on July 13, 2017 fraud charges involving 412 defendants in 41 federal districts across … Continue reading this entry

What To Know About New HHS OIG Exclusion Regs

Regulatory-Developments
On Jan. 12, 2017, the Office of Inspector General of the U.S. Department of Health and Human Services issued the third and final installment of its recent three-part rulemaking effort — a final rule updating its exclusion regulations, 82 Fed. Reg. 4100 (Jan. 12, 2017). This final rule follows two others that were published in December updating the OIG’s civil monetary … Continue reading this entry

CMS Revokes Billing Privileges for Competitive Bid Supplier

The Centers for Medicare and Medicaid Services (CMS) has demonstrated that it will not hesitate to use one of its most crippling administrative enforcement tools—the revocation of Medicare billing privileges—against one of its largest suppliers, as is evident in its case against Arriva Medical, LLC. Medicare billing privileges may be revoked for any one (or … Continue reading this entry

OIG Rings in the New Year With New Anti-Kickback Statute Safe Harbors

Just in time for the New Year, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services issued final regulations (Final Regulations) that revised two existing Anti-Kickback Statute safe harbors, added two regulatory safe harbors to complement existing statutory safe harbors, and created an entirely new safe harbor regarding local … 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

AHCA Sues to Enjoin Prohibition on Binding Arbitration

On October 4, 2016 CMS issued its Final Rule entitled “Reform of Requirements for Long Term Care Facilities” which updates the requirements for all SNFs and NFs participating in Medicare and Medicaid. Many of the changes impact quality of care, discharge, behavioral health issues and related issues associated with the general direction of CMS to … Continue reading this entry

Hospital Short-Stay Review Ban Lifted by CMS

Effective September 12, 2016, the Centers for Medicare & Medicaid Services (CMS) lifted the temporary ban on patient status reviews of hospital short stays for Medicare beneficiaries. Those reviews are currently conducted by the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs).1 As of October 1, 2015, the responsibilities of the BFCC-QIOs include … Continue reading this entry

Mid-Year 340B Program Update

Since our last 340B Drug Pricing Program (340B Program) update, the U.S. Centers for Medicare & Medicaid Services (CMS) has issued two regulations, the final Medicaid managed care regulation and a proposed update to the Medicare outpatient prospective payment schedule to implement new site neutrality requirements, that impact the 340B Program.  Providers participating in the … Continue reading this entry

CMS Proposes New Medicare Telehealth Coding Rules

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

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

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

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

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

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

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

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

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

Recent EHR Meaningful Use Program Updates

American Hospital Association Recommends Revisions to Medicare ACO Models
As we enter the sixth year of the Medicare and Medicaid Electronic Health Records Incentive Programs (commonly referred to as the “Meaningful Use Programs”), the Centers for Medicare & Medicaid Services (CMS) continues to make adjustments to the Meaningful Use Programs to better accommodate providers and suppliers. Two recent updates are described below.… Continue reading this entry

CMS Proposes Additional Changes to MSSP Regulations

Regulatory-Developments
The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule modifying the Medicare Shared Savings Program (MSSP) regulations (the “Rule”). Among other changes, the Rule proposes (a) to modify the method in which cost benchmarks for MSSP-participating Accountable Care Organizations (ACOs) are updated both during a three-year agreement period and upon renewal, and … 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

Bipartisan Budget Act Section 603's Impact on Off-campus Hospital Departments

Medicare’s 60-Day Proposed Refund Rule Imposes Significant Liability on Providers
This post was co-authored by Partner Cheryl Storey of Moss Adams LLP. Section 603 of the Bipartisan Budget Act of 2015 was initially passed to cut payments to hospital departments in order to provide funding to lift the Federal debt ceiling, increase domestic spending in Fiscal Year 2016, and keep Medicare Part B premiums down. … Continue reading this entry

Potential Part B Drug Payment Cuts for 340B Hospitals

The influential Medicare Payment Advisory Commission (MedPAC) has voted to recommend to Congress in its March report that Medicare Part B drug payment rates for 340B drugs be reduced by 10 percent for hospitals participating in the 340B Drug Pricing Program (340B Program). Currently, hospitals are paid the same rate by Medicare for drugs whether … Continue reading this entry

Senate Workgroup’s Proposals Address Chronic Illness Through Medicare

The Senate Finance Committee chronic care working group recently released a Policy Options Document continuing an effort that started with a hearing titled, “Chronic Illness: Addressing Patients’ Unmet Needs” in the summer of 2014. The workgroup, which is led by Chairman Orrin Hatch, Ranking Member Ron Wyden, and Senators Johnny Isakson and Mark Warner, compiled … Continue reading this entry

Medicare Proposes to Increase RAC Use

By now, providers are very familiar with Medicare recovery audit contractors, or RACs – the private companies who have authority to review medical records at a moment’s notice. For every dollar they opine has been improperly billed, the RACs recover a share of the bounty, creating a perverse incentive and an appeal process years behind … Continue reading this entry

Transforming Oncology Care: What’s Working and What Lies Ahead

Oncology providers and payors are undertaking bold initiatives to transform our system of “sick” care into a component of the value-based system of the future. The evolving system focuses on proactively monitoring and coordinating care by a team of providers working in concert to deliver care more efficiently and keep patients healthier. From payment changes … Continue reading this entry

2016 Will Be the Year of Telemedicine and ACOs

If 2015 was the year that brought telemedicine directly to consumers, 2016 will be the year of telemedicine and Accountable Care Organizations (ACOs). ACOs are expected to increase the use of telemedicine technologies as a way to improve patient quality, achieve greater cost savings, and meet Center for Medicare & Medicaid Services’ (CMS) patient threshold.… Continue reading this entry

State Lawmakers Pushing Telemedicine Coverage in 2016

State legislation is heavily contributing to the expected reimbursement/coverage uptick in 2016, as more states consider legislation requiring coverage for telemedicine and in-person visits alike. To date, 29 states and Washington D.C. have enacted legislation ensuring that private insurers offer reimbursement for telemedicine at equivalent levels with in-person services, provided the care is deemed medically … Continue reading this entry