Medicare Advantage

News & Analysis as of

Summary of Major Provisions in the Proposed 2017 Physician Fee Schedule

The proposed Physician Fee Schedule for 2017 (PFS) includes several changes covering a litany of topics spanning from telehealth services to expanding the Diabetes Prevention Program Model. The following is a high-level...more

Check Up on Healthcare Fraud Prosecutions

Chief compliance officers face an overwhelming level of risk in the healthcare sector. I do not mean to belittle the risks of corruption, AML, sanctions and other risks typically associated with global companies. Healthcare...more

DOJ Challenges Health Insurance Merger

On July 21, 2016, the Department of Justice, Antitrust Division (the “DOJ”) announced that it, along with several state attorneys general, would sue to block two multi-billion dollar health insurance mergers between Aetna and...more

Aveta And The Use Of Confidential Info In FCA Cases

In a recent case in the District of Puerto Rico, United States ex rel. Valdez v. Aveta Inc., et al., No. 15-cv-01140-CCC (D.P.R.), the former president of Puerto Rican-based managed health care provider Aveta Inc., Jose...more

CMS Proposes Medicare Physician Fee Schedule Update for 2017

The Centers for Medicare & Medicaid Services (CMS) has published its proposed rule to update the Medicare physician fee schedule (MPFS) for calendar year (CY) 2017. The proposed rule contains numerous Medicare payment and...more

Obama Administration, Congress Take Steps to Fight Opioid Epidemic

HHS has announced a series of actions to address the nation’s opioid epidemic, as Congress has cleared the Comprehensive Addiction and Recovery Act for the President’s signature. As part of the HHS activities, the Substance...more

CMS Issues Medicare Physician Fee Schedule Proposed Rule

On July 7, 2016, CMS issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017 (Proposed...more

Committees Approve Rural Hospital Relief, ESRD Benefits, Medical Countermeasures Bills

On July 13, 2016, the Ways and Means Committee approved HR 5659, which would enable Medicare beneficiaries with end stage renal disease (ESRD) to enroll in Medicare Advantage plans. Earlier this month, the Committee approved...more

Ways and Means Approves Bill to Delay LTCH 25% Rule Implementation, Make Other LTCH Reforms

On July 13, 2016, the House Ways and Means Committee approved an amended version of H.R. 5713, the “Sustaining Healthcare Integrity and Fair Treatment Act of 2016” or “SHIFT Act.” The primary focus of the SHIFT Act is to...more

Summary: PAMA Final Rule

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

Manatt on Medicaid: Transparency and Decision Support for Medicaid Managed Care Consumers

Editor's Note: This "Manatt on Medicaid" is the eighth in a series of updates focused on CMS's new Medicaid/CHIP managed care regulations. In the coming weeks, Manatt will be exploring key provisions of the regulations and...more

So You’re an Overpaid Medicare Part C/D Provider or Supplier: Can You Keep the Change?

The Centers for Medicare & Medicaid Services (“CMS”) published the long-awaited final rule February 12, 2016, clarifying the specific procedures applicable to the statutory requirement under the Affordable Care Act (“ACA”)...more

California Insurance Commissioner Asks DOJ to Block Proposed Mergers

On June 23, 2016, California Insurance Commissioner Dave Jones submitted a letter urging the Department of Justice, Antitrust Division (DOJ) to block the proposed merger between Aetna, Inc. (Aetna) and Humana, Inc. (Humana). ...more

Health Update - June 2016

Real-Time Data Analytics in Government Investigations and Reducing Exposure - It is not every day that the words “innovative” and “nimble” are used when referring to an agency of the federal government bureaucracy. Yet,...more

Broad Examination of Narrow Networks: First-of-Its-Kind Study Examines Hospitals in Medicare Advantage Plans

On June 20, 2016, The Kaiser Family Foundation issued the first ever broad-based study of Medicare Advantage hospital networks. The study — "Medicare Advantage Hospital Networks: How Much Do They Vary?"— analyzed 409 plans in...more

All About APMs: What Will It Take for Physicians to Earn the APM Bonus Under MACRA?

On May 9, 2016, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule addressing the implementation of physician payment reforms included in the Medicare Access and CHIP Reauthorization Act of 2015...more

House Approves “Helping Hospitals Improve Patient Care Act of 2016”

The House of Representatives has approved H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016,” as amended by the Ways and Means Committee in May. As previously reported, while the bill focuses on Medicare...more

Ways and Means Committee Approves Bill to Make Reforms to Medicare Hospital and Other Payment Policies

The House Ways and Means Committee has approved an amended version of H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016.” While most of the provisions address Medicare payment policies pertaining to...more

OIG, GAO Examine Medicare & Medicaid Program Integrity/Provider Screening Issues

The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) have recently examined a number of Medicare and Medicaid provider screening and related program integrity issues....more

No More Bidding – CMS 2, EGWPs 1

This Spring, CMS informed MAOs that offer Medicare Advantage EGWPs (employer group waiver plans) that they were no longer required to submit annual bids for EGWPs. Based on CMS’s explanation of why it adopted this change, it...more

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On May 6, 2016, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule entitled, “Patient Protection and Affordable Care Act; Amendments to Special...more

CMS Finalizes Major Reforms of Medicaid/CHIP Managed Care Rules

On May 6, 2016, CMS is publishing a final rule to update Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations to more closely align with Medicare Advantage (MA) and private health plan standards,...more

MA Changes Shift Funding and Add Uncertainty to Already Complex Payment Methodologies

In Depth - The Centers for Medicare & Medicaid Services has enacted significant changes to Medicare Advantage (MA) payment methodologies that will shift payment towards MA organizations (MAOs) enrolling significant...more

CMS publishes final Medicaid managed care rule

On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) released its long-awaited Medicaid managed care Final Rule, the first update to Medicaid managed care regulations since 2002, and implements dozens of...more

CMS Issues Final 2017 Medicare Advantage Capitation Rates and Medicare Advantage/Part D Payment Policies

CMS has issued its final 2017 Medicare Advantage (MA) and Part D Rate Announcement and Call Letter, which includes a series of policy and payment changes related to these programs. CMS estimates that the final policies will...more

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