Medicare

News & Analysis as of

OIG Questions Incentives for Hospice Care in Assisted Living Facilities

Today the OIG issued a report examining the growing use of Medicare hospice care in the assisted living facility (ALF) setting. According to the OIG, Medicare payments for hospice care in ALFs grew by more than 119% from 2007...more

Medicare DMEPOS Competitive Bidding Window is Now Open

The bidding window is now open for the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program Round 2 Recompete and the National Mail-Order Recompete for diabetic testing...more

OIG Recommends Greater Scrutiny for Hospice Services in ALFs

The OIG’s recently released study examining Medicare hospice claims from 2007 to 2012 calls for targeted reviews of hospices that receive a high proportion of their payments for care in assisted living facilities....more

MedPAC Voices Concerns about Growing Volume, Burden of Medicare Quality Measures

In December 2014, CMS released a 329-page list of quality measures under consideration for the Medicare program. In a January 13, 2015 comment letter, MedPAC observes that volume of measures under consideration “reinforces...more

First Circuit Reaffirms FCA’s “First-to-File” Bar as a Broad Jurisdictional Limit

In early December 2014, the United States Court of Appeals for the First Circuit reaffirmed that circuit’s broad interpretation of the False Claims Act’s “first-to-file” bar, 31 U.S.C. § 3730(b)(5), in United States ex rel....more

Stage 3 EHR Incentive Program, Health IT Certification Rules at OMB

HHS has sent to the White House Office of Management and Budget (OMB) for final regulatory clearance a proposed rule on Stage 3 meaningful use criteria for the Medicare and Medicaid Electronic Health Record (EHR) Incentive...more

CMS Publishes Medicare QIO Criteria

CMS has published notices setting forth the criteria it will use to evaluate the effectiveness and efficiency of Quality Innovation Network (QIN) and Beneficiary and Family Centered Care (BFCC) Quality Improvement...more

OIG Examines Appropriateness of Medicare Ophthalmology Claims

The OIG recently assessed the appropriateness of claims submitted by providers for screening for, diagnosing, evaluating, or treating cataracts, wet age related macular degeneration (wet AMD), and glaucoma in 2012....more

CMS Announces DMEPOS/Home Health/Hospice RAC, Improvements to RAC Process

CMS has announced that it has awarded the Region 5 Recovery Audit contract to Connolly, LLC (although the General Accounting Office subsequently reported that a bid protest has been filed regarding this award). The purpose of...more

CMS Guidance on Provider Timeframes for Responding to Additional Documentation Requests

CMS has updated the Medicare Program Integrity Manual to clarify that providers and suppliers have 45 days to produce documents in response to a pre-payment review Additional Documentation Request (ADR) issued by a Medicare...more

New Limitations on RAC Program

In March 2014, CMS temporarily suspended the Recovery Audit Contractor (RAC) program until it secured new contracts. The contracts for the program expired in June 2014, and in August, CMS said that it would restart the...more

Medicare chief Tavenner stepping down; oversaw rocky health care rollout

News Alert: Medicare Chief Tavenner stepping down!!!! WASHINGTON — Medicare chief Marilyn Tavenner — who oversaw the rocky rollout of the president’s health care law — says she’s stepping down at the end of February....more

Pharmacy Qui Tam Based On U&C Price Billing Survives Motion to Dismiss

Once again, a pharmacy employee has filed a qui tam involving a drug discount program, alleging that the failure of the pharmacy to use the discounted pricing as the “usual and customary” price in Medicaid and Medicare Part D...more

Health Care Enforcement in 2015: A Look Back on 2014 and Forecasting the Year Ahead

In testimony before the House Oversight and Government Reform Subcommittee on Health Care in April 2011, the now-pending nominee for U.S. Attorney General, Loretta E. Lynch, stated in no uncertain terms that “fighting health...more

What You Need To Know About the AKS Proposed Local Transportation Safe Harbor

On October 3, 2014, the Office of Inspector General of the U.S. Department of Health and Human Services (OIG) published a proposed rule to expand the safe harbors and make other modifications applicable to the federal...more

The $10,000 Access Clause

This paragraph (or some variation) finds its way into lots of contracts when one or both of the parties to the contract are participants in the health care industry...more

AHA Responds to House Bill Concerning RACs and Two-Midnight Rule

In a December 18, 2014 letter to U.S. Representative Kevin Brady, the American Hospital Association (AHA) voiced its opinion on a discussion draft of the Hospital Improvements for Payment Act of 2014 (HIP). The House Ways and...more

Medicare Enrollment Rules - Expanded Enforcement Finalized in Regulations

On December 5, 2014, CMS published final regulations that expand the bases for CMS to deny enrollment or revoke billing privileges of an enrolled provider or supplier. These final regulations also change the method to...more

CMS Proposes Changes to the Medicare Shared Savings Program MSSP

On December 1, 2014, CMS published its proposed changes and updates to the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs). Comments are due by February 6, 2015. Below is a summary of the...more

CMS Issues Final Rule on Reimbursement for Chronic Care Management Services

On November 13, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Medicare Physician Fee Schedule final rule, including a new code and guidance for billing for chronic care management services (CCM),...more

Debate Intensifies Over Medicare Advantage Plans’ Removal of Providers

Which is more important in a Medicare Advantage plan: the plan’s flexibility to change its provider list during the plan year, or the enrollees’ right to confidence that their providers won’t be removed from the plan after...more

Government Joins Lawsuit Against Florida Doctor Alleging Fraud and Kickbacks

In a move demonstrating the government’s continued aim to combat health care fraud through its Health Care Fraud Prevention and Enforcement Action Team (HEAT), the Department of Justice announced today that the government has...more

Residents Can Be Hazardous to a Community Hospital's Medicare Health

Although Medicare graduate medical education reimbursement can be a helpful source of financing to facilitate resident training, many community hospitals have suffered a “gotcha” moment when trying to establish new programs....more

CMS Releases Key Proposals for the 2016 Qualified Health Plan Application Process

Stakeholders received insight on the Obama administration’s expected approach to the certification and oversight of qualified health plans (“QHPs”) on December 19, 2014, with the release by the Centers for Medicare & Medicaid...more

Effects of the New Federal Spending Package on the Health Sector

In mid-December, President Obama signed into law a $1.1 trillion spending bill known as the “Consolidated and Further Continuing Appropriations Act, 2015” or “Cromnibus.”[1] This post explores provisions that relate to the...more

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