Hospital chains Hospital Corporation of America (HCA) and Tenet Healthcare Corporation (Tenet) announced on April 12th that the Centers for Medicare & Medicaid Services (CMS) has admitted that it erroneously calculated the rural floor provision established by the Balanced Budget Act of 1997. According to the HCA press release: [T]he rural floor provision establishes that a]… Continue Reading
Category Archives: Reimbursement
Subscribe to Reimbursement RSS FeedCMS Issues Final Rule Impacting Medicare Advantage and Medicare Part D Programs for Contract Year 2013
Posted in Payors & PBMs, ReimbursementWritten by Roy Albert, Susan Berson, and Tara Swenson The Centers for Medicare & Medicaid Services (“CMS”) recently published final regulations implementing program and technical changes to the Medicare Advantage (“MA”) and Medicare Prescription Drug (“Part D”) benefit programs. In the final rule, CMS addressed comments from various stakeholders on the proposed regulations published… Continue Reading
New York Court Finds Private Right of Action Under State’s Prompt Pay Law
Posted in Hospitals & Health Systems, Long-term Care/Skilled Nursing Facilities, Payors & PBMs, ReimbursementWritten by Nili S. Yolin On February 22, 2012, a New York State Court held for the first time that a provider may bring a claim against a health insurer under the State’s prompt pay law (PPL). New York’s PPL states that where there is an undisputed obligation to pay a claim, the insurer must… Continue Reading
CMS Publishes Proposed Rule on Return of Medicare and Medicaid Overpayments
Posted in Fraud & Abuse, Health Care Reform, ReimbursementWritten by Karen S. Lovitch and Stephanie D. Willis Health care providers and suppliers concerned about how the Centers for Medicare & Medicaid Services (CMS) plans to implement the 60-day deadline for returning Medicare and Medicaid overpayments enacted as part of the Affordable Care Act (ACA) now have a proposed rule that provides some insight…. Continue Reading
CMS Posts MLR Guidance: Payments to Entities such as IPAs, PHOs, and ACOs
Posted in Accountable Care Organizations, Health Care Reform, Reimbursement, UncategorizedWritten by Gary Bacher CMS posted additional sub-regulatory guidance regarding the Medicare Loss Ratio (MLR) under Section 2718 of the Public Health Service Act, as added by the Affordable Care Act (ACA). The MLR requires health insurance issuers to submit a MLR report to the Secretary of Health and Human Services and issue a rebate… Continue Reading
OIG Warns Physicians of Fraud Liability from Medicare Reassignments
Posted in Fraud & Abuse, Physicians, Reimbursement, State & Federal Audits, Investigations & Litigation, UncategorizedWritten by Karen S. Lovitch and Stephanie D. Willis An OIG Alert issued today reminds physicians who reassign their right to submit claims to and receive payment from Medicare may be liable for any false claims submitted to the government. The OIG linked this alert to recent settlements under the Civil Monetary Penalty Law with physicians whose Medicare payment reassignments resulted in false… Continue Reading
OIG Issues 2011 Fall Semiannual Report to Congress
Posted in Fraud & Abuse, Reimbursement, State & Federal Audits, Investigations & Litigation, UncategorizedWritten by Stephanie D. Willis The OIG’s 2011 Fall Semiannual Report describes the actions the agency undertook between April 1 and September 30, 2011 and summarizes its Medicare and Medicaid claims reviews and its legal, investigative, and monitoring activities. These monitoring activities now employ the enhanced “data mining, predictive analytics, trend evaluation, and modeling” technology discussed… Continue Reading
CMS Publishes Final Medicare Physician Fee Schedule for CY 2012
Posted in Clinical Laboratories, Health Care Reform, Physicians, ReimbursementYesterday CMS released the Medicare Physician Fee Schedule Final Rule for CY 2012, along with a press release and fact sheet summarizing key issues, which include: imposition of a 27.4% payment reduction based on the Sustainable Growth Rate (SGR), absent subsequent action by Congress (which it has taken every year but one since the SGR formula was… Continue Reading
CMS, OIG, DOJ, FTC Release New Interim and Final Rules on ACOs
Posted in Accountable Care Organizations, Fraud & Abuse, Hospitals & Health Systems, Reimbursement, UncategorizedWritten by Stephanie D. Willis Today, CMS released the final rule that will implement the Medicare Shared Savings Program (MSSP) mandated by section 3022 of the Affordable Care Act. Simultaneously, the Department of Justice’s Antitrust Division and the Federal Trade Commission released their joint “Statement of Antitrust Enforcement Regarding Accountable Care Organizations Participating in the… Continue Reading
Maxwell-Jolly: Supreme Court Considers Whether Supremacy Clause Can be Used to Challenge State Medicaid Rate Cuts
Posted in Reimbursement, State & Federal Audits, Investigations & Litigation, UncategorizedThe Supreme Court has just heard oral argument in a case that raises the issue of whether Medicaid providers and recipients can challenge state decisions to cut Medicaid rates. The court’s decision could have repercussions far beyond Medicaid rate-setting, as plaintiffs unhappy with any state decision begin searching for a federal statute that conflicts with,… Continue Reading
Innovation Center Extends Bundled Payments Initiative Application Deadlines
Posted in Accountable Care Organizations, Health Care Reform, Hospitals & Health Systems, Payors & PBMs, Reimbursement, UncategorizedWritten by Stephanie Willis The Center for Medicare and Medicaid Innovation has extended the deadlines for submitting letters of intent and final applications for participation in the Bundled Payments for Care Improvement Initiative. On August 23rd, Innovation Center Director Dr. Rick Gilfillan, together with Valinda Rutledge, Director of the Patient Care Models Group, and Senior… Continue Reading
