Medical Reimbursement

News & Analysis as of

Managing the Transition to Transformation: Alternative Payment Systems: Evolving Compliance Challenges

McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and care delivery...more

Manatt on Health Reform: Weekly Highlights - November 2016 #2

CMS authorizes Massachusetts waiver supporting transition to a Medicaid ACO model; Oregon CCOs use “flexible service” funds to invest in housing-related services; and enrollment for 2017 Marketplace coverage begins....more

Indiana Supreme Court Extends the Stanley Doctrine to State-Sponsored Medical Reimbursements

On October 21, 2016, the Indiana Supreme Court weighed-in on a closely watched case that drew much attention from the defense and plaintiff’s bar alike. Approximately one (1) year ago, I reported that the Indiana Court of...more

Managing the Transition to Transformation: Old Dog, New Tricks: Fraud and Abuse in the Age of Payment Reform

McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and care delivery...more

Commercial Insurers Urge Congressional Budget Office to Consider their Telemedicine Data

In hopes of expanding reimbursement opportunities for telemedicine services in the Medicare program, representatives of eleven payers, including Aetna, Anthem, Blue Cross Blue Shield of Tennessee, Cambia Health Solutions and...more

Insurer Liable for Mandatory Double Damages for Failure to Reimburse a Medicare Advantage Organization for Medicare Benefits It...

Humana Medical Plan, Inc. v Western Heritage Insurance Company ____ F.3d ____ 2016 WL 4169120 (11th Circuit, August 8, 2016) - The federal Medicare and Medicaid Acts have been called “among the most completely...more

Healthcare Litigation - October 2016

Recently, California Governor Jerry Brown signed into law “surprise medical bill legislation,” seeking to curb out-of-network medical bills. This law, designated AB 72, amends California’s Health and Safety Code to limit the...more

Eleventh Circuit Finds Mere Existence Of Insurance Contract Satisfies Condition Precedent To Action For Double Damages Under The...

The Eleventh Circuit Court of Appeals recently held that a private insurance company/PART C Medicare Advantage Organization (MAO) may sue a Personal Injury Protection (PIP) insurance carrier for reimbursement of medical...more

Sixth Circuit Denies Seal of Approval for Unjustified Filings Under Seal

Litigants and third parties subpoenaed to produce information in litigation who believe that information that they deem confidential will not ever become part of the public record so long as a discovery protective order is in...more

Healthcare Compliance: Juggling Risk Mitigation Strategies

Healthcare organizations – ranging from physician practice groups to large, multi-state hospital systems – face a variety of risks, including fraud and abuse, as well as HIPAA privacy issues. Starting from a baseline risk...more

Look, up in the sky! It’s a bird, it’s a plane, it’s… uh oh… a Super Lien!

Liability insurers have always gnashed teeth over the dreaded “super lien” – aka a lien asserted by Medicare for treatment expenses where the patient is reimbursed through a settlement obtained in personal injury litigation....more

11th Circuit Awards Humana Double Damages Under Medicare Secondary Payer Act

Humana Medical Plan, Inc. v. Western Heritage Insurance Co., case number 15-11436. Liability insurers beware, as the 11th Circuit held that Medicare Advantage Organizations (MAO) are entitled to the same rights...more

Medicare Advantage Organizations May Sue For Double Damages Under MSP Act - Humana Medical Plan, Inc. v. Western Heritage Ins....

On August 8, the Eleventh Circuit Court of Appeals decided an issue of first impression in the circuit under the Medicare Secondary Payer (MSP) Act. In sum, the Eleventh Circuit held that a Medicare Advantage Organization...more

CMS Proposes OPPS Reimbursement Adjustments: What Hospital Outpatient Providers Need to Know

In early July, the Centers for Medicare & Medicaid Services (CMS) proposed Hospital Outpatient Prospective Payment System (OPPS) reimbursement rule changes that will impact reimbursement payment amounts and requirements for...more

CMS Issues Pay Increase for Inpatient Psychiatric Facilities

On July 28, 2016, CMS issued a notice updating the prospective rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities. Beginning in fiscal year 2017, inpatient psychiatric facilities will...more

APMs, MIPS, and the Final MSSP Rule - The Journey from Volume to Value-Based Reimbursement Continues

Since the Affordable Care Act was enacted, many providers have been shifting away from traditional fee-for-service, volume-based reimbursement models to payment mechanisms that take a data-driven approach to managing patients...more

Round Up The Usual And Customary Suspects: Insurers May Determine UCR Prices By Shopping At Retail Outlets

For more than a decade, medical providers have tried to limit the discretion of automobile insurers to pay less than the billed amount for services and equipment offered to injured insureds. Most of these efforts involve...more

Site-Neutral Billing Exemptions

The Balanced Budget Bill Act of 2015 has a site-neutral billing provision relating to off-campus hospital outpatient departments (HOPDs). Those are facilities away from the hospital campus but certified as part of the...more

Reducing the Delay Between FDA Approval and CMS Reimbursement Coverage

The Centers for Medicare & Medicaid Services (CMS) recently confirmed that the Parallel Review program (first announced in 2010 and most recently extended until December 18, 2015) will be made permanent. ...more

Trove of SNF Claims Data Released By CMS – Ready for Mining By Auditors and Whistleblowers

Over recent years, the Federal government has trained its sights on potential billing abuses in the Medicare Part A program for Skilled Nursing Facilities (“SNFs”) in the provision of rehabilitation therapy services. The...more

Comprehensive Primary Care Plus Model: Today's Alternative Payment Model for Primary Care Providers Could Be Tomorrow's Obligatory...

In an effort to affect how approximately 25 million Medicare beneficiaries and other commercial insurance patients receive primary care services, the CMS Innovation Center (the "Innovation Center") announced the Comprehensive...more

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged...more

Time to Review Plan Subrogation Procedures, Part 2

I blogged a few days ago about the U.S. Supreme Court decision making it harder for plans to recover from a third-party settlement fund for the amount the plan paid when a participant is injured by that third-party. A recent...more

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On March 24, 2016, the Food and Drug Administration (FDA) issued a guidance entitled, “Draft Guidance for Industry: General Principles for Evaluating the Abuse Deterrence of Generic...more

MedPAC Report Recommends Reduction in Medicare Part B Payments to 340B Hospitals

On March 15, 2016, the Medicare Payment Advisory Commission (MedPAC) released its latest report to Congress that included 340B Implications for Medicare Part B Drugs along with a quick fact sheet regarding the report. Key...more

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