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Health Reform + Related Health Policy News - September 2014, Issue 1

In This Issue: - Top News ..The Congressional Agenda is Light as the Focus Shifts to the Midyear Elections ..Physician Supervision Requirement for Small and Rural Hospitals ..CMS Offers Hospitals...more

Department of Justice Files First False Claims Act Lawsuit Against Physician-Owned Distributorship

On Sept. 8, 2014, the United States Department of Justice (DOJ) filed a 98-page civil complaint alleging that investment returns, paid to a Michigan spinal surgeon and other physicians by a spinal implant company partially...more

Health Headlines: Also in the News - September 2014 #3

Congressman Sends Letter to Secretary of HHS Urging Her to Retract CMS’s Global Settlement Offer – On September 15, 2014, Congressman Kevin Brady (R-Tex), Chairman of the House Ways and Means Health Subcommittee, sent a...more

Whistleblower Defendant Blows Whistle on Whistleblower

Antonio Saidiani filed a whistleblower suit alleging that NextCare urgent centers and CEO Dr. Shufeldt had collected tens of millions of dollars in false Medicare claims. Antonio was in a position to know because he was that...more

OIG Reports Medicare Part B Supplying and Dispensing Fees Significantly Higher Than Those Under Part D and Medicaid

According to a recently released report from the HHS OIG, pharmacies are reimbursed significantly more for dispensing drugs under Medicare Part B than they would be for dispensing the same drugs under Medicare Part D and...more

House Passes Bill Requiring Post-Acute Providers to Collect Patient Assessment Data

The House recently passed its version of The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (H.R. 4994/S. 2553), which would require various post-acute providers, including inpatient rehabilitation...more

New Hospice Cost Report Released: Effective for Cost-Reporting Periods Beginning Next Week

On August 29, 2014, the Centers for Medicare and Medicaid Services (“CMS”) released the final version of the new Medicare cost report, Form CMS 1984-14, applicable to freestanding hospice providers. Freestanding hospice...more

OIG Report Reveals Twelve Percent of RHCs Do Not Meet RHC Certification Requirements

On September 12, 2014, OIG released its report regarding CMS’s enforcement of the statutory provisions governing Rural Health Clinics (RHCs). According to OIG’s report, twelve percent of RHCs no longer meet the location...more

CMS Releases MSSP and Pioneer ACO Data on Shared Savings and Losses – Where Do We Go From Here?

On September 16, 2014, the Centers for Medicare & Medicaid Services (CMS) announced key shared savings and losses results of Accountable Care Organizations (ACOs) that began participating in the Medicare Shared Savings...more

Court Dismisses AHA’s Challenge to CMS Billing Policy

On September 17, 2014, the U.S. District Court for the District of Columbia dismissed a lawsuit brought by the American Hospital Association (AHA), three individual hospitals, and two health care systems that challenged CMS’s...more

OIG Warns Pharma Its Copayment Coupons May Aid Crime

Brand name drugs cost a lot. So to make them more attractive, drug manufacturers issue coupons for discounts on the copayment portion of the price. They work the same as the dollar-off coupons offered by cereal manufacturers....more

OIG Issues Special Advisory Bulletin Covering Manufacturer Copay Coupons and Medicare Part D

For years, many drug manufacturers have issued coupons to help cover some or all of the cost of copayments (commonly referred to as a “copay”) for prescription medications. While the Department of Health and Human Services...more

CMS Continues to Struggle with How to Provide High Quality Care to Dual Eligibles

Last week CMS announced that it would not execute its option to terminate its 2015 contracts with Medicare Advantage Plans and Part D plans that had scored three stars or less for three consecutive years. ...more

D.C. Circuit Declines Hospitals’ Plea for Relief from CMS Catch-22

Here’s how the catch works. A hospital admits and treats a Medicare patient who needs care. The hospital bills Medicare and gets paid. Later—usually much later—a RAC auditor rules that the patient needed only outpatient care...more

What Employer Shared Responsibility Does Not Say

So much energy has been spent on what the final regulations on the employer shared responsibility tax and the related final reporting regulations (the “ESRR”), that some of the most significant considerations have been missed...more

Medigap Policy Contract with Preferred Hospital Networks Approved by OIG

On August 18, 2014, the U.S. Department of Health & Human Services, Office of Inspector General (OIG) issued another advisory opinion approving a licensed insurance broker’s proposal to establish a preferred hospital network...more

Wall v. VistaCare, Inc.: Successor Liability for Medicare Providers

A recent decision in the Northern District of Texas provides helpful guidance for health care corporations looking to limit their potential successor liability for Medicare fraud and overpayments. On August 4, 2014, U.S....more

Whistleblower Hotline Providers Can Even Save Lives

My mom and dad both have jobs in medicine, so I am some what familiar with how doctors, nurses, and specialists run their practice. My mom works with cancer patients so when I came across this rather shocking article about a...more

HHS Asserts the Everybody-Does-It Defense

If that sounds familiar, your child may have a future as a lawyer for Health & Human Services. Because that’s one of the primary arguments asserted by HHS last Friday in its motion to dismiss the lawsuit by the American...more

Attention Hospitals! Act Now To Get 68 Cents For Your Medicare Dollar!

It’s no secret that CMS is drowning in appeals from denials of Medicare claims for inpatient care. The number of pending appeals was estimated at half a million back in February, and it’s only grown since then. One reason...more

Want To Complain About The 2015 Medicare Physician Fee Schedule? Take A Number.

Apparently Americans feel that way about Medicare’s traditional fee-for-service physician compensation schedule. Everybody complains about it, but nobody likes any proposed changes. That’s clear from the reaction to the...more

A (Second) Lawsuit Seeks to Compel Statutory Timeframe for Administrative Law Judge Review of Medicare Claims Appeals

On August 26th, the Center for Medicare Advocacy filed a nationwide class action lawsuit against the Secretary of Health and Human Services. The complaint alleges that, as implemented, the Medicare administrative review...more

CMS Offers Global Settlement of Inpatient Status Claims with Pending Appeals

On August 29, 2014, the Centers for Medicare & Medicaid Services (“CMS”) announced a global settlement offer to acute care and critical access hospitals with currently pending appeals of inpatient status claims denials....more

Hospitals File Lawsuit Over Medicare ALJ Hearings Delays

Over 460,000 appeals requesting hearings before an administrative law judge (ALJ) were pending in the Office of Medicare Hearings and Appeals (OMHA) at the end of 2013, with 15,000 new appeals being submitted each week. At...more

A Primer on Medicare Requirements for Physician Supervision of "Incident to" Services

Services provided by a physician’s auxiliary staff that are “incident to” the physician’s services are paid under the physician fee schedule at a higher rate, as though the physician had personally furnished the services....more

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