Medicare

News & Analysis as of

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On April 21, 2016, CMS issued a proposed rule entitled, “Medicare Program: FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements.” This...more

To be prepared is half the victory

In the second in our series of alerts relating to drug pricing, we identify several considerations and potential actions that a pharmaceutical or biotechnology company can take to address the current headwinds impacting...more

Manatt on Health Reform: Weekly Highlights - April 2016 #4

CMS's sweeping final rule aligns Medicaid and CHIP managed care with QHP and Medicare Advantage regulations; New York's DSRIP is enabling change in the State's Medicaid delivery system; and Medicaid expansion reduces...more

IRS Denies Tax Exemption to Commercial ACO

On April 8, 2016, the IRS released a final adverse exemption determination with respect to an accountable care organization (ACO) formed by an unnamed nonprofit health care system. The adverse determination confirms and...more

Federal Court Rejects Hospitals’ Challenge to Medicare Wage Rule 

In a decision with far-reaching implications within the health care industry, on February 22, 2016, a federal judge rejected a challenge to how Medicare reimbursement is adjusted based on local labor costs, dismissing...more

There Is Such a Thing as Being Too Careful

According to The New York Times, Medicare may be punishing hospitals—and academic medical centers (AMCs) in particular—for being too careful. That’s how Northwestern Memorial Hospital’s chief medical officer sees the...more

A New Decision Under the False Claims Act Could be of Great Help to the Healthcare Industry

When it comes to the False Claims Act, the government usually wins, but a recent decision should provide the healthcare industry with a rare sigh of relief. The opinion in United States v. AseraCare Inc.1 acknowledges the...more

GAO Recommends Additional Site-Neutral Medicare Payment Policies

On April 13, 2016, the Government Accountability Office (GAO) released another report once again recommending that Congress equalize payment rates for Medicare services across practice settings (e.g., hospital outpatient...more

Ninth Circuit Denies Medicare Payments in Assets-Only Purchase Without Assignment of Provider Agreement

On April 11, 2016, the Ninth Circuit Court of Appeals ruled that a hospital was not entitled to Medicare payments in an assets-only purchase until the Buyer enrolled in the Medicare program because it did not accept the...more

Jury Sides with Defendant in Whistleblower's Suit Alleging Defendant "Caused" False Claims

Abbott Laboratories recently won a jury verdict in a high profile qui tam lawsuit alleging that Abbott “caused” health providers to submit false Medicare payment claims for off-label use of biliary stents. U.S. ex rel....more

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On April 15, 2016, the Food and Drug Administration (FDA) issued a proposed rule entitled, “Applications for Approval and Combinations of Active Ingredients Under Consideration for...more

CMS Announces Comprehensive Primary Care Plus, a Multi-Payer Initiative to Improve Primary Care

On April 11, 2016, CMS announced its launch of the “largest-ever multi-payer initiative to improve primary care in America.” The effort is titled the Comprehensive Primary Care Plus (CPC+) model, and will build on the...more

New Guidance on Exclusion

For the first time in nearly 20 years the Office of Inspector General (OIG) of the Department of Health & Human Services has issued new guidance on the exercise of its authority to exclude health care providers from...more

OIG laments failure to comprehensively address EHR fraud

The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) recently released a compendium (Compendium) of its top unimplemented recommendations. The Compendium comprises 25 unimplemented past OIG...more

Court Dismisses Major False Claims Act Case Against Hospice Provider: Ruling Mere Difference of Medical Opinion is Insufficient...

On March 31, 2016, the United States District Court for the Northern District of Alabama in U.S. ex rel. Paradies v. AseraCare, Inc. dismissed a major False Claims Act case against a national hospice provider after ruling...more

GAO Report Shows Medicare Bearing Largest Burden from Sequestration Cuts

Medicare cuts comprised 58% of all sequestration savings in fiscal year (FY) 2014 — $11.3 billion out of $19.4 billion in total sequestration funds — according to a new GAO report. Under current sequestration law,...more

CMS’ New Initiative Intended to Transform Primary Health Care

CMS’ efforts to improve the delivery of primary health care moved into new territory this week when the agency announced a new five-year delivery model, Comprehensive Primary Care Plus (CPC+), which CMS’ chief medical officer...more

Existence of Outstanding Medicare Lien Not Sufficient to Stall Settlement Payment

In Keith Karpinski v. Smitty’s Bar, Inc. (No. A143381), the California Court of Appeal for the First District held that the satisfaction of statutory liens, including those imposed by Medicare, is not necessarily a condition...more

CMS Announces Major Multi-Payer Comprehensive Primary Care Plus (CPC+) Model

CMS has launched a new “Comprehensive Primary Care Plus” (CPC+) model to improve how primary care is delivered and reimbursed. According to CMS, the CPC+ initiative (which builds on the ongoing Comprehensive Primary Care...more

OIG Examines Hospice Medicare Billing for General Inpatient Care

According to a recent OIG report, hospices billed inappropriately almost one-third of Medicare general inpatient care (GIP) stays in 2012, resulting in $268 million in inappropriate Medicare payments. The GIP level of care...more

CMS Announces New Alternative Payment Model for Primary Care

Earlier this week, CMS announced the launch of an initiative aimed at transforming the way primary care is delivered. The Comprehensive Primary Care Plus (CPC+) model will be a voluntary 5 year program accommodating some...more

Texas-Size Sentences for Texas-Size Medicare Fraud

They do things big in Texas. The latest example is the punishments being handed out for a Medicare fraud scheme at Riverside General Hospital in Houston. Let’s start with the fraud scheme. It was Texas-size, too,...more

HHS to Apply Medicare Rates for Physician, Other Health Services Purchased by IHS-Funded Programs

Sylvia Mathews Burwell, Secretary of the U.S. Department of Health and Human Services (HHS), on March 21, 2016, issued a final rule to apply Medicare payment methodologies to all physician and other health professional...more

HRSA reveals new tool for rural GME

In the face of rural physician shortages, the Health Resources and Services Administration (HRSA) unveiled a new tool on April 11 to help assess whether a rural hospital is currently a teaching hospital. Knowing whether a...more

OK to Exaggerate How Long Patients Need Device

Today’s riddle: Why would a federal court approve a medical device manufacturer’s practice of persuading physicians to exaggerate the period of time Medicare patients need their devices? The answer is so simple that you’ll be...more

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