MACs

News & Analysis as of

New York State Requires PBM Contracts to Include a Mechanism for Appealing Disputes Related to Generic Drug Pricing

On December 11, 2015, Senate Bill 3346-B[1] was signed into law by New York State Governor Andrew Cuomo. The new bill requires contracts between pharmacy benefit managers (“PBMs”) and pharmacies (or pharmacies’ contracting...more

Health Care E-Note - January 2016

The 2016 Medicare Physician Fee Schedule Final Rule ("Final Rule") contains recent changes to the Federal Stark Law, the majority of which took effect on January 1, 2016. The issuance of the Final Rule on November 16, 2015...more

Medicare: Congress Ends 2015 With Some Last-Minute Reforms

Congress chose to end 2015 with some last-minute Medicare reforms impacting healthcare providers. Significantly, the Patient Access and Medicare Protection Act, signed into law by President Obama on December 28, 2015,...more

OIG Work Plan Series – Installment Four – Oversight of Contracts

The Department of Health & Human Services’ Office of Inspector General (“OIG”) released its 2016 Work Plan, which includes the OIG’s focus on various aspects of federal government contracts. This alert will focus on the new...more

CMS Implements Changes to Prospective Payment System for Long-Term Care Hospitals

The Centers for Medicare & Medicaid Services (CMS) has implemented a revised payment system for Long-Term Care Hospitals (LTCHs). The changes, which became effective on October 1, define two separate payment categories for...more

New Restrictions: CMS Limits Scope of Review on Redeterminations and Reconsiderations for Certain Audit Appeals

On August 13, 2015, the Centers for Medicare & Medicaid Services (CMS) issued instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for...more

CMS Limits the Scope of Review for Certain Redeterminations and Reconsiderations

For providers who have received inconsistent or varying reasons for denial while navigating through the Medicare appeals process, the Centers for Medicare & Medicaid Services (CMS) has provided much-needed relief in the form...more

CMS Limits Scope of Review for MACs

CMS issued a special edition MLN Matters meant to be effective August 1, 2015. The guidance reflects CMS instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the...more

Cinderella May Not Turn Into a Pumpkin After All: The Proposed Relaxation of the Two-Midnight Rule

On July 8, 2015, the Centers for Medicare and Medicaid Services (“CMS”) released a Proposed Rule regarding the 2016 Hospital Outpatient Prospective Payment System (“OPPS”). The Proposed Rule, in addition to proposing updates...more

Key Ruling In False Claims Act Case Could Have Important Implications For Defendants

A recent decision out of a United States District Court in Alabama may signal that the playing field traditionally dominated by the government will no longer be so one-sided against providers defending against False Claim Act...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 Proposes to Modify—but Continues to Stand Behind—its “Two-Midnight” Rule

The “Two-Midnight” rule is a Centers for Medicare and Medicaid Services (“CMS”) billing policy which bases the appropriateness of payments for inpatient services under Medicare Part A versus Part B on provider expectations...more

Dentists Who Write Prescriptions Must Make a Decision: Enroll in Medicare or Opt-Out

If you are a dentist who writes prescriptions to Medicare beneficiaries for drugs covered under Medicare Part D, this article contains important information for you and your patients regarding your new enrollment requirements...more

CMS Issues DSH Ruling 1498-R2

CMS recently issued Ruling 1498-R2 (Ruling), dated April 22, 2015, amending its 2010 Ruling 1498-R. The new Ruling addresses the calculation of the Medicare fraction of the disproportionate share hospital (DSH) adjustment for...more

Private equity transactions in the UK: the essential differences from the US market

A US private equity fund seeking to acquire a target in the UK will soon notice a number of differences from the US market. It is important to be aware of these differences if you are competing against UK private equity...more

Timeline tightens for provider, supplier responses to MAC and ZPIC requests starting April 6, 2015

MAC and ZPIC reviewers have the right to request additional documentation when a claim itself is insufficient to make a payment determination. Effective April 6, 2015, in response to a pre-payment review and additional...more

CMS Guidance on Provider Timeframes for Responding to Additional Documentation Requests

CMS has updated the Medicare Program Integrity Manual to clarify that providers and suppliers have 45 days to produce documents in response to a pre-payment review Additional Documentation Request (ADR) issued by a Medicare...more

Health Headlines: Also in the News - January 2015

MACS to Hold Certain 2015 Date-of-Service Claims – CMS announced on December 29, 2014, that Medicare Administrative Contractors will hold claims containing 2015 services paid under the Medicare Physician Fee Schedule (MPFS)...more

CMS Instructs MACs to Participate in ALJ Hearings

CMS officially added a new Section 3.9 to the Medicare Program Integrity Manual, effective October 27, 2014. These provisions instruct Medicare Administrative Contractors (MACs) to assign a physician to participate at...more

CMS Provides for Greater MAC Involvement in ALJ Hearings

CMS recently issued Transmittal 543, Change Request 8501 in which it instructs Medicare Administrative Contractors (MACs) to, among other things, defend their medical review decisions through the Administrative Law Judge...more

Health Headlines: Also in the News - October 2014

On September 30th, the Food and Drug Administration (FDA) released draft guidance concerning the proposed oversight framework for regulating laboratory developed tests....more

GAO Issues Report on Post-Payment Claims Reviews by CMS Contractors

The U.S. Government Accountability Office (GAO) recently issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Post-Payment Claims Reviews,” which...more

Court Enjoins CMS From Enforcing Dissatisfaction Requirement When a Provider’s Appeal Stems from the MAC’s Failure to Issue a...

On August 6, 2014, the United States District Court for the District of Columbia enjoined CMS, its Medicare Administrative Contractors (MACs), and the Provider Reimbursement Review Board (PRRB) from applying the...more

The Probe and Educate Process For The Two-Midnight Rule

On August 2, 2013, the Centers for Medicare and Medicaid Services (“CMS”) released the final rule for the 2014 Medicare Inpatient Prospective Payment System (“IPPS”), effective October 1, 2013.[1] Introduced in the IPPS...more

OIG Reports that Two MACs are Responsible for $4 Million in Overpayments for Outpatient Drugs

According to two reports issued by OIG on July 25, the Medicare Administrative Contractors (MACs) for Jurisdictions 13 and 14 made overpayments of approximately $2.7 million and approximately $1.3 million, respectively, for...more

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