Medicare

News & Analysis as of

OIG Issues Special Advisory Bulletin Covering Manufacturer Copay Coupons and Medicare Part D

For years, many drug manufacturers have issued coupons to help cover some or all of the cost of copayments (commonly referred to as a “copay”) for prescription medications. While the Department of Health and Human Services...more

CMS Continues to Struggle with How to Provide High Quality Care to Dual Eligibles

Last week CMS announced that it would not execute its option to terminate its 2015 contracts with Medicare Advantage Plans and Part D plans that had scored three stars or less for three consecutive years. ...more

D.C. Circuit Declines Hospitals’ Plea for Relief from CMS Catch-22

Here’s how the catch works. A hospital admits and treats a Medicare patient who needs care. The hospital bills Medicare and gets paid. Later—usually much later—a RAC auditor rules that the patient needed only outpatient care...more

What Employer Shared Responsibility Does Not Say

So much energy has been spent on what the final regulations on the employer shared responsibility tax and the related final reporting regulations (the “ESRR”), that some of the most significant considerations have been missed...more

Medigap Policy Contract with Preferred Hospital Networks Approved by OIG

On August 18, 2014, the U.S. Department of Health & Human Services, Office of Inspector General (OIG) issued another advisory opinion approving a licensed insurance broker’s proposal to establish a preferred hospital network...more

Wall v. VistaCare, Inc.: Successor Liability for Medicare Providers

A recent decision in the Northern District of Texas provides helpful guidance for health care corporations looking to limit their potential successor liability for Medicare fraud and overpayments. On August 4, 2014, U.S....more

Whistleblower Hotline Providers Can Even Save Lives

My mom and dad both have jobs in medicine, so I am some what familiar with how doctors, nurses, and specialists run their practice. My mom works with cancer patients so when I came across this rather shocking article about a...more

HHS Asserts the Everybody-Does-It Defense

If that sounds familiar, your child may have a future as a lawyer for Health & Human Services. Because that’s one of the primary arguments asserted by HHS last Friday in its motion to dismiss the lawsuit by the American...more

Attention Hospitals! Act Now To Get 68 Cents For Your Medicare Dollar!

It’s no secret that CMS is drowning in appeals from denials of Medicare claims for inpatient care. The number of pending appeals was estimated at half a million back in February, and it’s only grown since then. One reason...more

Want To Complain About The 2015 Medicare Physician Fee Schedule? Take A Number.

Apparently Americans feel that way about Medicare’s traditional fee-for-service physician compensation schedule. Everybody complains about it, but nobody likes any proposed changes. That’s clear from the reaction to the...more

A (Second) Lawsuit Seeks to Compel Statutory Timeframe for Administrative Law Judge Review of Medicare Claims Appeals

On August 26th, the Center for Medicare Advocacy filed a nationwide class action lawsuit against the Secretary of Health and Human Services. The complaint alleges that, as implemented, the Medicare administrative review...more

CMS Offers Global Settlement of Inpatient Status Claims with Pending Appeals

On August 29, 2014, the Centers for Medicare & Medicaid Services (“CMS”) announced a global settlement offer to acute care and critical access hospitals with currently pending appeals of inpatient status claims denials....more

Hospitals File Lawsuit Over Medicare ALJ Hearings Delays

Over 460,000 appeals requesting hearings before an administrative law judge (ALJ) were pending in the Office of Medicare Hearings and Appeals (OMHA) at the end of 2013, with 15,000 new appeals being submitted each week. At...more

A Primer on Medicare Requirements for Physician Supervision of "Incident to" Services

Services provided by a physician’s auxiliary staff that are “incident to” the physician’s services are paid under the physician fee schedule at a higher rate, as though the physician had personally furnished the services....more

Corridors Fall 2014 - News for NC Hospitals

In this issue: - North Carolina’s Medicaid RAC Program – Don’t Let Your Guard Down - A Primer on Medicare Requirements for Physician Supervision of “Incident to” Services - Hospital Options for Unused...more

Medicare Bundled Payments Initiative and Oncology Care

According to Modern Healthcare’s “Interest Surges in Medicare Bundled Payment Initiative” article on July 31, 2014, enthusiasm for bundled pricing has been associated with the Medicare Bundled Payments for Care Improvement...more

7th Circuit Defines "Worthless Services" Under the False Claims Act

That’s the upshot from U.S. ex rel. Absher v. Momence Meadows Nursing Center, Nos. 13-1886 & 13-1936 (Aug. 20, 2014), a recent decision from the Seventh Circuit (authored by Judge Manion) that addressed the worthless-services...more

CMS Waves Partial White Flag in Appeals of Payment Status Denials

For the last several years, hospitals, on the one hand, and the Centers for Medicare and Medicaid Services and its contractors (collectively, CMS), on the other, have been engaged in a spirited dispute over claims denials for...more

What's the Difference Between Medicare and Medicaid in the Context of Long-Term Care?

Although their names are confusingly alike, Medicaid and Medicare are quite different programs. Both programs provide health coverage, but Medicare is an “entitlement” program, meaning that everyone who reaches age 65 and is...more

Telehealth and Health IT Policy: Considerations for Stakeholders

In recent months, as the conversation about reforming the health care system has shifted to achieving greater delivery system efficiencies, cost containment, and patient satisfaction, the role of health care...more

Medicare Increases Coverage of Mental Health Services

Medicare has increased the amount of mental health coverage beneficiaries are entitled to. After years of unequal treatment, Medicare now covers mental health care the same way it covers physical illnesses....more

CMS Says: Let's Make a Deal

In the hours before everyone began enjoying Labor Day Weekend, the Centers for Medicare & Medicaid Services (CMS) issued an important inpatient hospital review update....more

Medicare Beneficiaries Sue HHS Over 489-Day Backlog in ALJ Appeals

The Center for Medicare Advocacy (CMA) filed a complaint last week on behalf of five Medicare beneficiaries in federal district Court in Connecticut requesting a court order requiring the Secretary of HHS to clear a massive...more

CMS Issues Final Rule for Inpatient Stays in Acute Care and Long Term Care Hospitals

On August 1, 2014, the Centers for Medicare and Medicaid Services (CMS) issued its annual final rule for policy and payment changes applicable to inpatient stays in acute care and long term care hospitals (Final Rule). This...more

OIG Advisory Opinion Approves Medigap Insurer’s Plan to Use Preferred Hospital Network

On August 25, 2014, the OIG released an advisory opinion declining to impose civil monetary penalties on a Medicare Supplemental Health Insurance – or Medigap – insurer that planned to discount inpatient hospital deductibles...more

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