News & Analysis as of

Health Alert (Australia) - October 5, 2015

In This Issue: - Judgments; Legislation; and Reports. - Excerpt from Judgments: Victoria. Epichealth Pty Ltd v Yang [2015] VSC 516 The Supreme Court has granted an interlocutory...more

Health Law Pulse - October 2015

The Health Resources and Services Administration (HRSA) recently issued proposed omnibus guidance (Omnibus Guidance) interpreting various provisions of the 340B Drug Pricing Program (340B Program). The 340B Program allows...more

CMS Posts CY 2016 Amount in Controversy Thresholds for Medicare Appeals

CMS has published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process....more

Yep, There’s a Billing Code for That

If you think you’re waiting even longer at your doctor’s office these days, you might be right. And it might be due to the overhaul of the medical billing code system that requires providers to enter an alphanumeric...more

OIG Flags $171 Million in Potentially Questionable Billing for Medicare Ophthalmology Services

The OIG has issued a report entitled “Questionable Billing for Medicare Ophthalmology Services.” The OIG concludes that most Medicare providers billing for ophthalmology services in 2012 did not demonstrate what the OIG...more

Justice Department Recovers Nearly $6 Billion From False Claims Act Cases in 2014

The U.S. Department of Justice (DOJ) obtained a record $5.69 billion in settlements and judgments from civil cases involving fraud and false claims against the government in fiscal year 2014. This marks the first time the DOJ...more

Suing the Hand that Feeds You

Jeffrey Jacobs alleges that Idaho’s Pocatello Hospital violated the False Claims Act because of physician recruitment contracts that were overly generous to his practice group. Jeff should know because he was recruited under...more

Uncovering the mysteries behind GME payments for Medicare Advantage patients: Carve-outs and shadow bills

Medicare makes graduate medical education (GME) payments to teaching hospitals to pay Medicare's share of the teaching and patient care costs associated with Medicare Advantage (MA) patients. Under the Balanced Budget Act...more

Primary Care Providers – Are You Feeling The Pinch?

It was nice while it lasted – due to a provision of the Patient Protection and Affordable Care Act (“ACA”), services furnished by certain primary care providers (“PCPs”) were subject to an enhanced payment rate for Calendar...more

CMS Corrects FY 2016 Medicare Payment Rules

CMS has released corrections to a number of fiscal year (FY) 2016 final Medicare payment rules. Specifically, on October 5, 2015, CMS is publishing corrections to...more

CMS Proposes Lab Data Collection Requirements to Update Fee Schedule

On September 25, 2015, CMS released proposed rulemaking that would extensively revise payment and reporting requirements for clinical diagnostic laboratory tests (CDLTs), as paid on the Clinical Laboratory Fee Schedule...more

OIG Again Calls for Reforms to Medicare SNF Reimbursement Policy

The HHS Office of Inspector General (OIG) continues to question the appropriateness of payments to skilled nursing facilities (SNFs) under the Medicare SNF prospective payment system (PPS). Based on Medicare Part A SNF claims...more

MedPAC Meeting on Medicare Policies (Oct. 8-9)

The next Medicare Payment Advisory Commission (MedPAC) meeting is scheduled for October 8 -9, 2015. Topics on the agenda include: Medicare drug spending; Alternative Payment Models and the Merit-based Incentive Payment...more

CMS Implements Changes to Prospective Payment System for Long-Term Care Hospitals

The Centers for Medicare & Medicaid Services (CMS) has implemented a revised payment system for Long-Term Care Hospitals (LTCHs). The changes, which became effective on October 1, define two separate payment categories for...more

Fast Alert: OIG Calls For Reevaluation Of Medicare Therapy Billing

On September 30, 2015, the Office of Inspector General (OIG) published a report titled, "The Medicare System For Skilled Nursing Facilities Needs To Be Evaluated" in response to growing concerns over Medicare's payment system...more

OMB Reviewing New Final Rule on ACO Waivers

Joint waivers issued by the Centers for Medicare and Medicaid Services (CMS) and HHS Office of Inspector General (OIG) relating the application of the physician self-referral law, the Federal anti-kickback statute, and...more

West Coast States Bolster Momentum for Pharmacist Provider Status Reforms

In recent years, legislative reforms have been introduced that recognize pharmacists as reimbursement-eligible providers under government-funded health care programs. While these efforts have attracted significant media and...more

OIG Calls for CMS to Reform Payment for Skilled Nursing Facility Services

The Office of Inspector General of the U.S. Department of Health and Human Services (OIG) issued a report on September 30, 2015, that calls for the Centers for Medicare and Medicaid Services (CMS) to reform payment for...more

Arbitration of Nursing Home Suits: Take Two

Quasi Tort Reform in Nursing Home Litigation Is on the Way! Last fall, I posted a blog about the national trend of including arbitration provisions in nursing home admission agreements. This trend peaked following the...more

Why Industry Drug-Assistance Programs Are a Sham

You probably heard about the recent price hike for a drug critical to AIDS patients when the manufacturer sold it to an evil hedge fund manager who promptly marked it up 5,000%. This prompted Los Angeles Times columnist...more

CMS to Host Call on Implementation of the IMPACT Act

On October 21, 2015, CMS is hosting a provider call to discuss the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The call will cover...more

When a Violation of a Rule or Regulation Becomes an FCA Violation: Understanding the Distinction Between Conditions of Payment and...

If you read one thing… - The False Claims Act’s (FCA) language, structure, court precedent and purpose limit its application to only regulatory breaches that are conditions of payment and not conditions of...more

IRS Levy Against Medicare Payments Increases to 100% Effective October 16, 2015

The Internal Revenue Code was amended in April 2015 as part of the Medicare Access and CHIP Reauthorization Act of 2015 to increase allowable IRS levies against federal payments, such as Medicare receivables, from 30% to 100%...more

CMS Releases Proposed Rule Reforming Medicare CLFS Payment Rates

The Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule [CMS-1621-P] in accordance with Section 216 of the Protecting Access to Medicare Act of 2014 (“PAMA”), which establishes a new payment methodology...more

A&B Healthcare Week In Review, September 2015

On September 25, 2015, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule entitled “Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System”. This proposed rule would...more

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