News & Analysis as of

MACs

CMS issues new guidance on interim rates for new teaching hospitals

by Dentons on

Prompted by confusion among Medicare Administrative Contractors (MACs) regarding how to initiate payments to new teaching hospitals, CMS issued on September 22, 2017, a One-Time Notification, Transmittal 1923, "Calculating...more

In Targeting Outlier Payment Reconciliation, OIG Calls for an Aggressive Reading of CMS Reopening Regulations

by King & Spalding on

The HHS OIG recently published a report detailing CMS’s and Medicare Administrative Contractor’s (“MACs’”) ongoing issues in the outlier payment reconciliation process. A previous 2012 review identified 465 cost reports that...more

CMS Expanding The "Targeted Probe And Educate" Audits Nationally This Fall

by Roetzel & Andress on

The Centers for Medicare and Medicaid Services (“CMS”) announced recently that it will be expanding its medical claims review program to cover the entire country by the end of this year. The expanded program, titled “Targeted...more

CMS To Expand Use of TPE Audits Nationwide by End of 2017

by Dorsey & Whitney LLP on

Perhaps lost amid the healthcare news coverage of competing proposals regarding “Medicare for All” and the repeal of Obamacare, the Centers for Medicare & Medicaid Services (“CMS”) last month announced the expansion of its...more

Targeted Probe and Educate – CMS Changes Its Approach to Auditing

by Baker Ober Health Law on

Medicare providers and suppliers will now be subject to Targeted Probe and Educate (TP&E) audits beginning this fall. These TP&E audits will focus on limited audits of individual providers and provider education. This new...more

CMS Implements Uniform Provider-Based Checklist

by Baker Ober Health Law on

CMS recently instructed its Medicare Administrative Contractors (MACs) to use CMS's electronic provider-based (PB) checklist. In a One-Time Notification, CMS advised that it had been receiving different PB checklists from its...more

GAO: CMS, MACs Should Bolster Provider Education to Cut Improper Medicare Payments

by Reed Smith on

In 2016, an estimated $41.1 billion in improper Medicare fee-for-services payments were made to providers. The Centers for Medicare & Medicaid Services (CMS) believes that provider education plays an important role in...more

The OIG 2017 Work Plan Includes Focus on Hospitals - Corridors Newsletter April 2017

by Poyner Spruill LLP on

The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) has issued its Work Plan for Fiscal Year 2017. The annual Work Plan provides a summary of new, revised, and continuing reviews for DHHS...more

Upcoming Cost Report Filings for FYE 12/31/2016 Subject to More Stringent Rules Prohibiting Payment of Items that Are not Claimed...

by King & Spalding on

The CY 2016 OPPS Final Rule, issued on October 30, 2015, instituted new cost reporting rules prohibiting MACs from paying items that a provider has not claimed or protested on its as-filed cost report. Importantly, these...more

D.C. District Court Upholds CMS’s Predicate Fact Three-Year Reopening Limitation

by King & Spalding on

On March 10, 2017, Judge John Bates of the U.S. District Court for the District of Columbia upheld CMS’s three-year cost report reopening limitation, as applied to “predicate fact” determinations. The regulation at issue is...more

It Ain't Over 'Till It's Over – First Circuit Rejects Settlement Agreements Between Providers and Intermediary and Upholds Cost...

by Baker Ober Health Law on

On October 27, 2016, a three-judge panel for the United States Court of Appeals for the First Circuit issued an opinion concluding that a Medicare fiscal intermediary (Intermediary) does not have the authority to enter into a...more

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

by Baker Ober Health Law on

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

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

by Baker Ober Health Law on

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

OIG Highlights Varying Local Medicare Part B Drug Coverage Policies; Recommends Single Entity to Make Drug Coverage Determinations

by Reed Smith on

The OIG has issued a report entitled “MACs Continue to Use Different Methods to Determine Drug Coverage,” which reviews how Medicare Administrative Contractors (MACs) make Medicare Part B drug coverage determinations and...more

D.C. District Court Invalidates CMS’s “Protest” Requirement

by King & Spalding on

On August 19, 2016, the United States District Court for the District of Columbia granted a group of hospitals’ motion for summary judgment against HHS in a challenge of the Provider Reimbursement Review Board’s (PRRB) denial...more

A Favorable, New Climate for Challenging Medicare Appeals

by Latham & Watkins LLP on

Over the past decade, health care providers seeking to challenge Medicare claim denials have faced increasing delays in reaching what many consider the most important step in the Medicare appeals process - a hearing before an...more

Bill to Make Local Coverage Determinations More Transparent Introduced in House

by King & Spalding on

On July 11, 2016, Reps. Lynn Jenkins (R-Kan.) and Ron Kind (D-Wis.) introduced the Local Coverage Determination Clarification Act (H.R. 5721), with the goal of modifying the LCD process performed by Medicare Administrative...more

CMS Revises Enrollment-Related Provisions in the Medicare Program Integrity Manual

by Arnall Golden Gregory LLP on

The Centers for Medicare & Medicaid Services (CMS) made changes to important written guidance to Medicare providers by issuing a Change Request on June 24, 2016, to Chapter 15 of its Program Integrity Manual (titled “Medicare...more

Summary: PAMA Final Rule

by Foley Hoag LLP on

Market Based Payment for Clinical Diagnostic Laboratory Tests - Summary - On June 17, 2016 the Centers of Medicare & Medicaid Services (CMS) issued the long awaited Medicare Clinical Diagnostic Laboratory Tests...more

CMS Limits MAC and QIC Scope of Review

by Baker Ober Health Law on

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

GAO Report Finds Medicare Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data

by King & Spalding on

On May 13, 2016, the U.S. Government Accountability Office (“GAO”) released a report on the review activities of the different Medicare claim review contractors that CMS uses to help reduce improper payments and protect the...more

CMS Temporarily Suspends QIO Patient Status Reviews of Short Stay Inpatient Claims under the Two Midnight Rule

by King & Spalding on

According to press reports, on May 4, 2016, CMS directed Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) tasked with reviewing the appropriateness of short stay inpatient claims under the...more

GWACs and MACs - Vital Tools for Small Business - Set-Aside Alert

by PilieroMazza PLLC on

Government-wide acquisition contracts ("GWACs")and multiple award contracts ("MACs")have become increasingly important to contractors and agencies, and they can be invaluable vehicles for small businesses. ...more

Seeing your first Medicare GME dollars

by Dentons on

Hospitals that decide to begin training residents and become new teaching hospitals often wonder when they will start to receive Medicare graduate medical education (GME) funding. Will the money come in the door the first day...more

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

by Epstein Becker & Green on

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

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