Medicare Part B

News & Analysis as of

CMS Releases Medicare Part B Supplier Billing and Payment Data

Potential for Increase in Whistleblower Litigation - On April 8, 2014, The Centers for Medicare & Medicaid Services (CMS) released, with tremendous fanfare, hundreds of thousands of points of billing data regarding...more

I’ll Be Watching You: Medicare Billing Info on over 880,000 Providers Released by CMS to Improve Transparency

Every payment you take, every claim you make, someone will be watching you. No, we don’t mean Sting. We mean all the consumers and businesses that will have greater access to physician billing information now because today...more

OMHA Holds Medicare Appellant Forum

On February 12, 2014, the Office of Medicare Hearings and Appeals (OMHA) held a “Medicare Appellant Forum” in Washington, DC. The event was well-attended, with 300 people signed up to be present in-person, and 500 who signed...more

2014 OIG Work Plan: Questionable Billing Patterns for Part B Services During Nursing Home Stays

The 2014 OIG Work Plan includes the following: Billing and Payments. We will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home...more

SGR-Driven Payment Reduction Postponed Again

As part of the Balanced Budget Act of 1997 (BBA), Congress enacted a number of payment reforms designed to curb the growth of expenditures under Medicare Part B. One of the more notable of those provisions was the Sustainable...more

OIG Recommends that CMS Scrutinize Clinicians with High Cumulative Payments

Focusing on clinicians who receive high cumulative payments under Medicare Part B could be a useful means of identifying possible improper payments, according to a recent report issued by the Office of Inspector General of...more

CMS Releases CY 2014 Hospital OPPS and ASC Final Rule

CMS has published its Calendar Year (CY) 2014 Final Rule for Medicare policy and payment rates for hospital outpatient prospective payment systems (OPPS) and Ambulatory Surgical Center (ASC) services. This final rule with...more

CMS Directs MACs to Reject Part B Ambulance Claims for SNF to SNF Transfers

On November 6, 2013, CMS issued Transmittal No. 1311 which instructed Medicare Administrative Contractors (“MACs”) to reject claims for SNF to SNF ambulance transfers that are billed separately under Part B. According to CMS,...more

CMS Attributes Significant Out-of-Pocket Savings for Medicare Beneficiaries to Health Care Reform Efforts

On October 28, 2013, CMS announced that Medicare beneficiaries are realizing significant out-of-pocket savings as a result of health care reform efforts. The savings are based on cumulative savings in the prescription drug...more

OIG Reports on The First Level of the Medicare Appeals Process

The HHS Office of Inspector General (OIG) recently published the results of a study regarding the first level of the Medicare Parts A and B appeals process, or redeterminations, for years 2008 through 2012. The report...more

FY 2014 IPPS/LTCH PPS Final Rule Goes Into Effect October 1, 2013

In This Issue: - What Providers Should Know - Requirements for Inpatient Admissions and Payment Under Medicare Part A - New Rules Permitting Re-billing Under Medicare Part B for Denied Admissions - New HAC...more

OIG Report Details Disproportionate Increase in Ambulance Usage

On September 24, 2013, the OIG issued a Memorandum Report titled “Utilization of Medicare Ambulance Transports, 2002-2011” analyzing the continued increases in ambulance usage among Medicare beneficiaries. The OIG found that...more

Federal District Court Rules Against Medicare Beneficiaries Challenging Observation Status

In Bagnall v. Sebelius, No. 3:11-CV-01703 (D. Conn.), a federal district court in Connecticut recently granted a motion to dismiss the complaint of fourteen Medicare beneficiaries seeking to invalidate an HHS policy allowing...more

Three-Month Implementation Period for “Two-Midnight” Rule to Begin October 1, 2013

CMS issued guidance on September 26, 2013, regarding the implementation of the “Two-Midnight” rule addressed in the August 2013 Inpatient Prospective Payment System (IPPS) final rule. Under the Two-Midnight rule, patient...more

CMS to Congress: Sequestration of Cancer Drug Reimbursement to Continue

A June 3, 2013 letter from CMS Administrator Marilyn Tavenner to Rep. Pete Sessions (R-Tex.) states that the agency does not believe it has any discretion under the Budget Control Act of 2011 to exempt Part B cancer drug...more

CMS Proposes New Standard for Hospital Inpatient Admissions

As part of its proposed inpatient prospective payment systems (IPPS) rule for FY 2014, CMS introduced a new standard for determining whether an inpatient admission to an acute care hospital is appropriate. Specifically, CMS...more

Available Recording of Roundtable on CMS Ruling 1455-R and Proposed Rule on Part B Rebilling Issues

King & Spalding recently hosted a Roundtable Webinar focused on CMS Ruling 1455-R and Proposed Rule 1455-P. Both of these developments are of great interest to the healthcare industry because they have a significant impact on...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

CMS Revises Part B Billing Policy for Unnecessary Inpatient Admissions

For many years, CMS policy has been that, if an inpatient admission was denied for medical necessity reasons, the hospital could bill under Part B for only a limited set of services that, significantly, did not include...more

CMS Offers Partial Concession to Hospitals by Issuing Ruling, Proposed Rule on Part B Re-Billing

The U.S. Centers for Medicare & Medicaid Services (CMS) recently released both a “ruling” and a proposed rule intended to address growing concern among hospitals about billing Medicare Part B following a medical necessity...more

CMS Ruling On Part B Rebilling After RAC Audits

On March 13, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a ruling contrary to its traditional billing policy regarding payment of Part B inpatient services following denial of a Part A claim. Ruling...more

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