Hospitals Patient Protection and Affordable Care Act (PPACA)

News & Analysis as of

Hospital Compliance Program Overview

?In the constantly evolving climate of health care enforcement, maintaining a comprehensive and effective internal compliance program has taken on added significance, especially in the past few years. While detailed coverage...more

The 60 Day Rule — Identification and Knowing Avoidance

On August 3, 2015, the United States District Court for the Southern District of New York issued an opinion and order in Kane v. Healthfirst, Inc., et al.[1] that provides the first judicial interpretation of the requirement...more

Five Lessons From 2015 Healthcare Deals

In 2015, we already have seen a great deal of activity in healthcare transactions that is attracting antitrust scrutiny, with mixed results. Among the winners have been Cabell and St. Mary's, which received state clearance...more

District Court Issues First Decision Interpreting ACA's 60-day Rule

The first case to interpret when the clock begins to run on the “60-Day Rule” did not go well for health care providers. On August 3rd, the Southern District of New York rejected defendants HealthFirst, Inc.’s and Continuum...more

Court Imposes Potentially Unworkable Burden on Providers Under ACA's Report and Return Rule

In Kane ex rel. U.S. v. Healthfirst, Inc., the federal district court for the Southern District of New York (District Court or Court) provided on August 3 the first and long-awaited interpretation as to when a health care...more

Identification of Overpayments: A Win for DOJ Cautions 'Prosecutorial Discretion' in Enforcement of an 'Unforgiving Rule'

On August 3, 2015, the Southern District of New York issued the first judicial opinion interpreting the Affordable Care Act’s “60-Day Overpayment Rule” in a False Claims Act (“FCA”) case. In a clear win for the Department of...more

Federal District Court Interprets 60-Day Overpayment Rule Trigger

In an eagerly anticipated decision issued on August 3, 2015, in an order denying the defendant hospitals’ motion to dismiss, the Southern District of New York became the first court to interpret and define the extent of a...more

When an Overpayment Becomes a False Claims Act Issue: Explaining the First Judicial Interpretation of the 60-Day Rule

On August 3, 2015, Judge Edgardo Ramos of the United States District Court for the Southern District of New York issued the first judicial opinion addressing when a health care provider has “identified” a Medicare or Medicaid...more

Kane and the “60-Day Rule”: The Unforgiving World of Medicare and Medicaid Overpayments

The Southern District of New York has spoken on one of the first issues to confront those seeking compliance with the new “60-day rule” under the Affordable Care Act (ACA), and it does not bode well for defendant hospitals...more

Fasten Your Seat Belts: District Court Says “Failure to Act Quickly Enough” May Violate 60-Day Refund Rule

A New York Federal District Court issued an Opinion and Order, on August 3, 2015, in a closely-watched False Claims Act (FCA) case, Kane v. Healthfirst, Inc. The Court refused to dismiss the whistleblower complaint in which...more

Washington Healthcare Update

This Week: Bipartisan Senate Letter Questions HHS and CMS on Details of State ACA Waivers...OMB Is Reviewing Final Medicaid-Covered Outpatient Drug Rule...Delaware Forgoes Transition to State-Based Exchange....more

The False Claims Act: Do You Really Have Just 60 Days to Repay?

One of your employees informs you of a potential overpayment from Medicare. Do you really only have 60 days from that point to determine if it is indeed an overpayment and repay it? The Patient Protection and Affordable...more

Blog: First Court Decision Interpreting the Overpayment Rule Issued This Week

Earlier this week, a key decision denying defendants’ motion to dismiss was issued in the case, Kane v. Healthfirst Inc., et al. and United States v. Continuum Health Partners Inc., et al. (case no. 1:11-cv-02325, S.D.N.Y.)....more

When Is An Overpayment “Identified?” The Answer Is In

In a highly anticipated ruling in Kane ex rel United States, et al. v. Health First, Inc., et al., a New York federal judge has issued the first judicial interpretation of the sixty-day overpayment return provision in the...more

CMS Issues Final FY 2016 Medicare IPPS/LTCH Rule

On July 31, 2015, the Centers for Medicare & Medicaid Services (CMS) released a major final rule to update the Medicare acute hospital inpatient prospective payment system (IPPS) and the long-term care hospital prospective...more

First Court Opinion on When an Overpayment is “Identified” for Purposes of the 60-Day Repayment Law

The court’s interpretation complicates the already difficult task providers face in having sufficient time to assess and quantify potential overpayments. An August 3 decision in United States v. Continuum Health Partners...more

Ignorance Is Not Bliss: The 60-Day Clock under the ACA’s “Return and Report Rule” Can Start Ticking Well Before the Exact Amount...

On August 3, 2015, a federal judge in the Southern District of New York ruled that the United States’ and state of New York’s complaints in intervention can move forward against a group of hospitals, under the federal False...more

SDNY Issues Groundbreaking Decision On False Claims Act Sixty-Day Rule

Medicare and Medicaid providers have an obligation to refund overpayments from federal health care programs. The False Claims Act (“FCA”) imposes liability for any person who “knowingly conceals or knowingly and improperly...more

Health Care Update - August 2015

CMS Releases Final Payment Rules (IPPS, IRF, LTCHs, Hospice, and Psych): At the end of last week, the Centers for Medicare and Medicaid Services (CMS) released a set of final 2016 payment rules affecting acute care hospitals...more

CMS Issues FY 2016 IPPS and LTCH Final Rule

On July 31, 2015, CMS issued its final rule to update the fiscal year (FY) 2016 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective...more

After Almost 25 Years--New Long-Term Care Regs: An Impressive and Costly Undertaking

On July 16, 2015, CMS released its long-awaited proposed changes for Medicare/Medicaid participation by long-term care (“LTC”) facilities. The new regulations represent the first comprehensive change to the requirements since...more

New Jersey Tax Court Eliminates Non-Profit Hospital’s Property Tax Exemption

On June 25, 2015, a New Jersey Tax Court issued a significant opinion in the case of AHS Hospital Corp. d/b/a Morristown Memorial Hospital v. Town of Morristown, upholding the Town of Morristown’s denial of Morristown...more

Anthem-Cigna Mega Merger Likely Problematic for Providers

Anthem announced on July 24, 2015 that it would purchase Cigna, just three weeks after Aetna agreed to buy Human for $37 billion. The deal is valued at $54.2 billion, and would create the United States’ largest health insurer...more

Washington Healthcare Update

This Week: CMS Releases Guidance on Fast Track Process for 1115 Waivers for Medicaid and CHIP... Healthcare.gov CEO Sends Letter to State Insurance Commissioners Concerning 2016 Premium Decisions... Medicare Board of Trustees...more

The Implications of CMS' Proposed Stark Law Regulations

On July 8, 2015, the Centers for Medicare & Medicaid Services (“CMS”) released proposed regulations “to reduce burden and to facilitate compliance” under the physician self-referral law known as the Stark Law. See 80 Fed....more

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