Centers for Medicare & Medicaid Services

News & Analysis as of

CMS Steps Up Efforts to Recover Overpayments from Providers/Suppliers Sharing TINs

CMS has just announced that it has enhanced its financial accounting system to allow it to recover Medicare payments made to a provider or supplier that shares the same Tax Identification Number (TIN) with a provider or...more

Final Rule Issued on ACA’s Non-Discrimination Provision for Federally Funded Programs

Section 1557 of the Affordable Care Act (“ACA”), in effect since 2010, prohibits discrimination in any federally funded health program on the basis of race, national origin, sex, age, or disability. The Department of Health...more

Health Update - June 2016

Real-Time Data Analytics in Government Investigations and Reducing Exposure - It is not every day that the words “innovative” and “nimble” are used when referring to an agency of the federal government bureaucracy. Yet,...more

CMS Overhauls Clinical Laboratory Fee Schedule with Long-anticipated Final Rule

On June 17, 2016, CMS released a long-anticipated final rule revising the Medicare payment system for clinical diagnostic laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) (the Final Rule). In 2018,...more

Maryland Co-Op Claims Risk Adjustment Formula Discriminates Against Smaller Insurers

Maryland’s Evergreen Health Cooperative has filed for an injunction against the federal government to halt payment by the Consumer Operated and Oriented Plan (co-op) of the $22 million it owes to CareFirst BlueCross...more

New ACO Rule: Continued CMS Efforts to Promote Program Participation

On June 6, 2016, 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”). The Final...more

CMS Finalizes Changes to Medicare Clinical Lab Test Payment Policy, Pushes Back Effective Date to 2018

On June 23, 2016, the Centers for Medicare & Medicaid Services (CMS) is publishing a major final rule to base Medicare clinical laboratory fee schedule (CLFS) reimbursement on private insurance payment amounts, as required by...more

Senate Passes Legislation to Delay Pending Medicare DMEPOS Fee Schedule Cuts Based on Competitive Bidding Prices

As previously reported, the Affordable Care Act mandates that CMS use pricing information from the durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program (CBP) to adjust...more

Health Care IT Program Discusses Alternative Payment Model Opportunities

A distinguished panel of providers, consultants and IT firms convened on Tuesday, June 21st in New York at the Foley and Lardner LLP offices to share a discussion focused on the convergence of IT spend and new value based...more

CMS Announces Pre-Claim Review Demonstration for Medicare Home Health Services

CMS has announced a new three-year Medicare “pre-claim review” demonstration for home health services in five states — Illinois, Florida, Texas, Michigan, and Massachusetts — with “high incidences of fraud and improper...more

Managing the Transition to Transformation: Is Your Organization Ready for the Shift to Alternative and Quality-Based Payment...

For many decades, at least since the passage of the Health Maintenance Organization Act of 1973, there have been reform efforts focused on moving the United States health care system away from fee-for-service (FFS)...more

Medicare Launches Home Health Pre-Claim Review Demonstration in Five States

The Centers for Medicare and Medicaid Services (CMS) recently announced it will implement a pre-claim review demonstration for home health services. The three-year demonstration will apply to home health services performed in...more

Understanding the Implications of MACRA, MIPS and APMs

On May 9, 2016, the Centers for Medicare & Medicaid Services (CMS) published a notice of proposed rulemaking to implement the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Although the...more

MedPAC Issues Recommendations on Medicare Drug, Post-Acute Care, and Other Payment Policies

MedPAC has released its June 2016 Report to the Congress on Medicare and the Health Care Delivery System. The report includes recommendations for a number of Medicare policy reforms and analyses of various health care market...more

CMS Proposes Changes to Hospital CoPs to Promote Quality, Strengthen Discrimination Protections

CMS has published a proposed rule on June 16, 2016 that would update the standards hospitals and critical access hospitals (CAHs) must meet to participate in Medicare and Medicaid. Specifically, CMS proposes to revise the...more

OIG Identifies Continued Vulnerabilities in Medicare Provider-Based Facility Payment Policy

A new OIG report examines CMS’s oversight of Medicare billing by provider-based facilities – that is, facilities that operate under the ownership, administrative, and financial control of a hospital and meet other...more

CMS Proposes Changes to Payment Error Rate Measurement (PERM) & Medicaid Eligibility Quality Control (MEQC) Programs

CMS has issued a proposed rule to make changes to the PERM and MEQC programs to align with changes to state adjudication of Medicaid and Children’s Health Insurance Program (CHIP) eligibility under the Affordable Care Act....more

Manatt on Health Reform: Weekly Highlights - June 2016 #4

Massachusetts releases $1.8 billion DSRIP program waiver for public comment; CMS awards $32 million in grants to enroll uninsured children in Medicaid/CHIP; and Wisconsin withdraws proposed changes to Medicaid long-term care....more

OIG Recommends Eliminating Provider-Based Designation for Facilities Owned by Hospitals

In a report released on June 17, 2016, OIG renewed its call for CMS to either eliminate the provider-based designation, which allows facilities owned by and integrated with a hospital to bill Medicare as a hospital outpatient...more

Manatt on Medicaid: CMS Revises Process for Determining MMC Payments

In its April 25, 2016 Medicaid managed care final rule, the Centers for Medicare and Medicaid Services (CMS) provides a revised framework for determining how managed care plans should be paid by state Medicaid programs. A...more

CMS Finalizes Changes to Medicare Shared Savings Program/ACO Benchmark Rebasing Rules

CMS has published a final rule that revises the methodology CMS uses to measure the performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program. According to CMS, the changes are intended to...more

All About APMs: What Will It Take for Physicians to Earn the APM Bonus Under MACRA?

On May 9, 2016, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule addressing the implementation of physician payment reforms included in the Medicare Access and CHIP Reauthorization Act of 2015...more

OIG Faults State Efforts to Identify 340B Drug Claims; Cites Risk of Duplicate Discounts, Forgone Rebates

The OIG recently examined how states that pay for drugs through Medicaid managed care organizations (MCOs) identify and exclude 340B drug claims when collecting Medicaid rebates, since states are prohibited from collecting...more

CMS Update on Temporary “Two Midnight” QIO Review Pause

CMS has temporarily “paused” Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) performance of initial patient status reviews under CMS’s “two-midnight policy” for short hospital stays. The...more

OIG Releases Report on Washington State’s Health Benefit Exchange

The OIG recently released findings that Washington’s Health Benefit Exchange (the “Washington Exchange”) needs to be improved to fully comply with federal requirements and to protect personally identifiable information (PII)....more

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