C&M Health Law

C&M Health Law

Analysis, commentary, and the latest developments in health care law and policy

Tag Archives: Medicare

Hospitals Beware: Medicare Electronic Health Records Incentive Payments to Hospitals are in the OIG’s Crosshairs

Posted in Digital Health, EHR, Fraud, Waste & Abuse, Health IT
The Department of Health and Human Services, Office of the Inspector General (OIG), modified its Work Plan to announce that the agency will be conducting a nationwide audit of hospitals that participated in the Medicare Electronic Health Records (EHR) Incentive Program (also known as the Meaningful Use Program).  The OIG review is focusing on hospitals… Continue Reading

CMS Issues Final Rules on MACRA Quality Payment Program Implementation

Posted in Medicare
On November 2, 2016, the final rule with comment period (the “Final Rule”) implementing provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) relating to the new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) will be published in the Federal Register.  The Center for Medicare and Medicaid Services (CMS) also launched… Continue Reading

OIG Updates Policy on Permissive Exclusions Based On Fraud and Kickbacks

Posted in Administrative Law, Fraud, Waste & Abuse, Medicare
The Office of the Inspector General of the Department of Health and Human Services (OIG) last week replaced a 20-year old policy statement, and issued guidance on the criteria the agency will use to evaluate whether to exclude certain individuals and entities from billing or “participation in” Federal health programs under its permissive exclusion authority.… Continue Reading

Next Generation ACO Model Enters its Second & Final Application Cycle

Posted in Health Care Reform & ACA
This month, the Centers for Medicare & Medicaid Services (CMS) announced the beginning of the second application cycle for its Next Generation ACO Model (Next Gen Model).  We discussed the goals of the Next Gen Model and how it compares to the Medicare Shared Savings Program and Pioneer ACO models in this post from last… Continue Reading

CMS Proposes New ACO Performance Measures

Posted in Health Care Reform & ACA, Medicare
On January 28, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would change the methodology used to evaluate and adjust the performance of Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). The proposed rule is intended to improve long-term incentives for ACOs and create a path for long-term… Continue Reading

C&M Alert on the “Overdue” 60-Day Overpayment Rule for Part A & B Providers

Posted in Fraud, Waste & Abuse
Our Health Care Group attorneys have authored a new alert explaining the implications of the final rule on the reporting and return of overpayments (the “Overpayment Rule”) the Centers for Medicare & Medicaid Services (CMS) issued earlier this month.  CMS promulgated the Overpayment Rule nearly two years after the agency issued its final rules governing… Continue Reading

CMS Announces Substantial Increase in ACO Participants for 2016

Posted in Health Care Reform & ACA
On January 11, 2016, the Centers for Medicare & Medicaid Services (CMS) announced that 100 new Accountable Care Organizations (ACO) began participating in the Medicare Shared Savings Program (MSSP). CMS also announced that 21 new providers and hospitals have signed up to participate in other ACO-focused shared savings programs, including the Pioneer ACO Model, Next… Continue Reading

Sequestration Extended to 2025 in Federal Budget Deal

Posted in Administrative Law, Litigation, Medicare
On November 2, President Obama signed the Bipartisan Budget Act of 2015. As an offset for near-term increases in federal spending, the new law extends by one year – to 2025 – two-percent sequestration reductions in federal spending for mandatory federal programs including Medicare.  The end result is that Medicare Advantage Organizations (MAOs) can expect… Continue Reading

CMS: Significant Provider Network Changes Gives MAO Enrollees Chance to Change Plans

Posted in Medicare
Medicare Advantage (“MA”) plans may want to think twice before modifying their provider networks.  In an August 27, 2015 letter, CMS announced that MA plan enrollees may elect to change plans if their current plan makes a significant provider network change with substantial beneficiary impact. The letter provides an overview of how CMS will implement… Continue Reading

CMS Issues Guidance on Part D’s “Any Willing Pharmacy” Requirement

Posted in Health Care Reform & ACA, Medicare
Citing concerns about transparency and timing, on August 13, 2015, CMS issued a memorandum to clarify guidance to Medicare Part D sponsors regarding the any willing pharmacy requirement. Medicare Part D sponsors are required to contract with any pharmacy that meets the Part D sponsor’s standard terms and conditions.  CMS requires that the standard terms… Continue Reading

CMS Proposes To Modify “Two-Midnight Benchmark” To Broaden Exceptions for Part A Payments for Short Inpatient Stays

Posted in Fraud, Waste & Abuse, Medicare
On July 8, 2015, CMS issued proposed regulations that would modify the “two-midnight rule” that governs payments by Medicare Part A for short inpatient hospital stays.  The proposed changes are contained in the CY 2016 proposed regulations for the Hospital Outpatient Prospective Payment System (OPPS).  Stakeholders may submit comments on the proposal by August 31,… Continue Reading

Mere Days After Comment Period Closed, CMS Abandons Four Aspects of CY 2015 Medicare Advantage and Part D Rule

Posted in Medicare
In a March 10, 2014 letter to Congress, CMS Administrator Marilyn Tavenner indicated that—based on concerns from Congress and the public—CMS shall not finalize the Proposed Rules’ proposals that would have: Removed the protected class definition for immunosuppressant drugs used in transplant patients, antidepressants, and antipsychotic medicines used to treat schizophrenia and certain related disorders… Continue Reading

Landmark False Claims Act Judgment: What Hospitals and Healthcare Providers Should Know

Posted in Fraud, Waste & Abuse, Litigation
On October 2, 2013, the federal district court in Columbia, South Carolina imposed a landmark $237 million judgment in a much-discussed False Claims Act case which was predicated on violations of the Physician Self-Referral (Stark) Law, U.S. ex rel. Drakeford v. Tuomey Healthcare System, Inc.1 The case was originally filed as a qui tam case… Continue Reading

Medicare Advantage and Part D MLR Final Rule Issued

Posted in Health Care Reform & ACA, Medicare
On May 20, 2013, the Centers for Medicare and Medicaid Services (CMS) released the final regulations on the Affordable Care Act’s (ACA) medical loss ratio (MLR) requirements for Medicare Advantage and Medicare Prescription Drug Benefit Programs (PDP). The final MLR rule is largely identical to the proposed rule and generally tracks the requirements of the commercial… Continue Reading