Medical Reimbursement

News & Analysis as of

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NOTICES, & GUIDANCE - On March 24, 2016, the Food and Drug Administration (FDA) issued a guidance entitled, “Draft Guidance for Industry: General Principles for Evaluating the Abuse Deterrence of Generic...more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

Supreme Court Rejects Private Suits to Challenge Medicaid Rate Reductions

One of the areas of healthcare impacted heavily by the Great Recession beginning in 2007 was Medicaid reimbursement. Cash-strapped states, in an attempt to alleviate budgetary issues, reduced Medicaid provider reimbursement...more

Big Payment Changes Revealed In New Medicare Part B Drug Payment Test

On March 8, 2016, the Centers for Medicare and Medicaid Services (CMS) unveiled a new Part B Drug Payment Model that, if implemented, would represent a radical change in Medicare reimbursement for outpatient drugs. The...more

Supreme Court Holds That ERISA Preempts State Health Care Services Disclosure Law

Preemption is not a foreign concept when dealing with the Employment Retirement Income Security Act of 1974 (ERISA). Preemption arguments frequently and increasingly arise, for example, in the context of claims by health care...more

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On February 24, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a guidance entitled, “Special Enrollment Confirmation Process” that will enhance program integrity...more

Not Fooling This Time: CJR Bundled Payments Begin April 1 for Covered Hospitals Nationwide

The promotion of “value not volume” in the health care delivery system is an important theme of the Affordable Care Act and many related efforts to reform the American health care system. In this context, Health and Human...more

Blog: Heath Provisions in President’s Budget Take Aim at Drug Prices and Opioid Abuse

Today, the President sent Congress the $4 trillion Fiscal Year 2017 Budget Proposal – his last while in office. While the Budget on the whole is dead on arrival in the Republican-controlled Congress, there are provisions...more

Do Your Assignment of Benefits Clauses Need a Check-up? Recent Southern District of Florida Decision Highlights the Importance of...

A frequently litigated issue in reimbursement cases brought by in- and out-of-network healthcare providers against insurers under the Employee Retirement Income Security Act of 1974 (“ERISA”) is provider standing. Because...more

Important Changes for Physicians from the 2016 Medicare Physician Fee Schedule: Part II (Non-Stark Changes)

On November 16, 2015 the Centers for Medicare and Medicaid Services (CMS) published the final Medicare Physician Fee Schedule (Final MPFS).1 The Final MPFS addresses changes to the physician fee schedule and related policies,...more

CMS Issues Final Rule Implementing Mandatory Bundled Payment Program for Lower Extremity Joint Procedures

The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule (Final Rule) that implements the Comprehensive Care for Joint Replacement model (CJR Model), a new bundled payment program covering certain...more

Fast Alert: OIG Calls For Reevaluation Of Medicare Therapy Billing

On September 30, 2015, the Office of Inspector General (OIG) published a report titled, "The Medicare System For Skilled Nursing Facilities Needs To Be Evaluated" in response to growing concerns over Medicare's payment system...more

West Coast States Bolster Momentum for Pharmacist Provider Status Reforms

In recent years, legislative reforms have been introduced that recognize pharmacists as reimbursement-eligible providers under government-funded health care programs. While these efforts have attracted significant media and...more

HHS Issues Proposed 340B Program Omnibus Guidance: Five Things to Watch

The 340B Drug Pricing Program (340B Program), established by Section 602 of the Veterans Health Care Act of 1992, is administered by the Health Resources and Services Administration (HRSA) of HHS. The 340B Program requires...more

Fenwick Employment Brief

California Legislature Acts to Outlaw Pre-Employment Mandatory Agreements to Arbitrate Labor Code Claims - In late August, the California Senate and Assembly passed AB 465, which, if signed by Governor Jerry Brown, will...more

3D Printing of Medical Devices: When a Novel Technology Meets Traditional Legal Principles

This white paper – 3D Printing of Medical Devices: When a Novel Technology Meets Traditional Legal Principles – explores the legal ramifications and risks of the rapidly increasing use of 3D printing of medical devices. 3D...more

Telehealth Commercial Coverage and Parity Laws: Trends, Challenges and Opportunities

There will always be differences among state laws on telehealth coverage, but what is remarkable is the rapidly increasing pace at which states have been adopting coverage statutes in the last few years, with currently 29...more

Waivers of Co-Pays and Deductibles: Insurance Benefit Exclusions Grow

Recent changes to policy and plan language and increased litigation by third-party payers suggests that out-of-network providers who waive co-pays and deductibles may be in for some rough sailing. Providers must be aware of...more

Connecticut Enacts Health Care Legislation in June Special Session

On June 29 and 30, 2015, the Connecticut General Assembly conducted a special legislative session following the close of the 2015 regular session. Among other things, the General Assembly passed a bill to implement the state...more

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