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Medicare Two-Midnight Rule and Observation Status Updates

What's new from Medicare in the areas of the Two-Midnight rule and observation services? CMS recently published updates to a Medicare manual reflecting clarifications to its Two-Midnight policy, a Medicare Quality Improvement...more

CMS Publishes the Medicare Outpatient Observation Notice Form and Instructions

On December 8, 2016, CMS published the final version of the Medicare Outpatient Observation Notice (MOON) that hospitals and critical access hospitals (referred collectively as "hospitals" herein) must use to provide notice...more

CMS Final Rule and 21st Century Cures Act Include Good and Bad News for Provider-Based Sites

CMS recently published its final outpatient prospective payment system (OPPS) rule, which includes its new policies governing payment related to services furnished at off-campus provider-based departments (OPBDs). 81 Fed....more

CMS Releases the 2016 OPPS Final Rule

On November 1, 2016, CMS published its final policy changes, quality provisions, and payment rates for 2017, as they relate to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center...more

Home Health Agency PPS Update for 2017: Quality, Quality, Quality

On November 3rd, CMS published the Final Prospective Payment System (PPS) Rule for Home Health Agencies (HHAs) for CY 2017 at 81 FR 76702 (Nov. 3, 2016). The rule implements annual changes to the PPS rate for HHAs and...more

D.C. District Court Strikes Down PRRB's Application of "Self-Disallowance" Jurisdictional

In Banner Heart Hospital, et al. v. Burwell, the United States District Court for the District of Columbia (Court) held on August 19, 2016, that the Provider Reimbursement Review Board (PRRB) incorrectly declined to hear an...more

The MOON Notification is Coming: CMS Publishes Final Changes

CMS is moving forward with implementing the Medicare Outpatient Observation Notice (MOON) as announced in its FY 2017 IPPS Final Rule [PDF] on August 2, 2016, and published in the Federal Register on August 22, 2016 (Final...more

D.C. District Ct Applies Prohibition on Administrative and Judicial Review to IRF PPS Rates

On July 25, 2016, Judge John D. Bates of the United States District Court for the District of Columbia issued a memorandum opinion broadly construing 42 U.S.C. § 1395ww(j) to prohibit administrative or judicial review of a...more

CMS Releases the 2017 IPPS and LTCH PPS Final Rule, Including MOON Requirements

On August 2, 2016, CMS issued its final rule addressing new payment rates and policies under both the Hospital Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System...more

Final FY 2017 Inpatient Psychiatric Facilities Payment and Policies Rule, Payment Matters

On August 1, 2016, CMS published the FY 2017 Inpatient Psychiatric Facilities (IPF) Prospective Payment System (PPS) – Rate Update notice. Some of the key changes are highlighted below....more

Proposed Cardiac, Hip, and Femur Episode Payment Models Are Next Generation from BPCI and CJR

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 25, 2016, entitled, Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and...more

CMS Releases the 2016 OPPS Proposed Rule

On July 15, CMS published its proposed policy changes, quality provisions, and payment rates for 2017 as they relate to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC)...more

Home Health PPS CY 2017 Proposed Rule: Payments Rebased, Quality Measures Updated

Downward adjustments to home health episode payments arising from rebasing of the national payment rates, case mix adjustments, and an increase to the fixed dollar loss ratio for calculating outliers will result in an overall...more

Medicare Appeals Backlog: HHS' Response to the Decade-Long Delay in Reviewing Appeals

The Department of Health and Human Services (HHS) published its proposed rule [PDF] revamping the Medicare appeals process at the Administrative Law Judge (ALJ) level on July 5, 2016. The proposed rule extensively revises...more

CMS Announces "Pause" in QIO Review of Inpatient Admissions

Last week CMS announced a temporary "pause" in the review of inpatient admissions by the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs). CMS posted this announcement on its Inpatient Hospital...more

CMS Limits MAC and QIC Scope of Review

Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) should not expand redeterminations and reconsiderations of claims denied on the basis of complex pre–or post–pay payments or automated...more

CMS's Proposed IPPS and LTCH FY 2017 Rule: Key Takeaways

On April 18, 2016, CMS released its proposed rule addressing new payment rates and policies under both the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS),...more

2-Midnight Rule Updates

- CMS Adopts Change to Benchmark and Shift in Enforcement - CMS Explains Reasoning Behind 0.2% Payment Reduction CMS has published discussions of the 2-midnight rule in two recent Federal Register publications. In the...more

CMS Issues CY 2016 HHA PPS, Value-Based Purchasing and Quality Reporting Final Rule

On November 5th, CMS published the Final PPS Rule for Home Health Agencies (HHAs) for CY 2016. The rule implements annual changes to the PPS rates for HHAs and represents the third year in a four-year rebasing of the rates....more

CMS Proposes Significant Revisions to Hospital Discharge Planning Process: How Patient Choice May be Impacted

On November 3, 2015, CMS released a proposed rule revising existing discharge planning requirements for hospitals, critical access hospitals (CAHs) and home health agencies (HHA). CMS stated impetus for doing so is to both...more

Court Upholds CMS Treatment of Multi-Campus Hospitals as Single Entities for Wage Index Purposes

The United States Court of Appeals for the District of Columbia recently upheld the decision of the Secretary of Health and Human Services (Secretary) that a multi-campus hospital straddling two geographic areas should be...more

Home Health, CY 2016 Proposed Rule: Emphasis on Value-Based Purchasing

On July 10, 2015, CMS published the calendar year (CY) 2016 home health prospective payment system (PPS) proposed rule [PDF]. While the proposed rule updates and revises certain payment rates and quality measures, it also...more

CMS Proposes Limited Exception to Two-Midnight Rule and QIO Review of Short Stays

In the 2016 inpatient prospective payment system (IPPS) proposed rule, CMS promised to provide further guidance on the controversial "two midnight" rule in the forthcoming outpatient prospective payment system (OPPS) rule....more

CMS Issues CY 2016 Proposed Rule for OPPS, ASC Payment Systems and Quality Reporting

On July 8, 2015, CMS published in the Federal Register [PDF] its proposed changes and updates to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy...more

CMS Pays $1.3 Billion to Hospitals for Settlements of Medicare Inpatient Appeals

On June 11, 2015, CMS announced that it had entered into settlements with over 1,900 hospitals for over 300,000 disputed inpatient billing claims. CMS updated its website dedicated to inpatient hospital reviews, noting that...more

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