News & Analysis as of

Outsourcing Ambulatory and Outpatient Services: What Hospitals Need to Know

We are in the midst of a trend involving the “outsourcing” of certain outpatient and ambulatory services by hospitals and health systems. These outsourcing transactions often involve partnerships with for-profit, specialty ...more

CMS Reopens the Medicare Payment Adjustment Hardship Exception Application Submission Period for Certain Providers and Hospitals

Centers for Medicare & Medicaid Services (CMS) recently announced the reopening of the submission period for hardship exception applications for eligible professionals and eligible hospitals that have been unable to fully...more

Deadline Approaching to Secure Health Plan Identifier (“HPID”)

Certain group health plans are required to obtain a 10-digit Health Plan Identifier ("HPID") from the Center for Medicare and Medicaid Services ("CMS") by November 5, 2014. Currently various users of the health care system...more

Notice 2014-67 ?? Safe Harbors for ACOs and a New Management Contract Safe Harbor for Everyone

On Friday, Oct. 24, 2014, the Internal Revenue Service released interim guidance, Notice 2014-67, on whether a state or local government entity or an organization described in §501(c)(3) of the Internal Revenue Code of 1986,...more

Report Shows CMP Enforcement Actions On the Rise Against Part C and Part D Sponsors

A new report issued October 16, 2014 by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) reveals that civil monetary penalty (CMP) enforcement actions in these two programs more than tripled from 2012 to 2013....more

IRS Releases Private Business Use Guidelines for ACO Participants

On Friday, October 24, 2014, the Internal Revenue Service (IRS) released Notice 2014-67, providing guidance regarding the circumstances under which participation by a hospital in an Accountable Care Organization (ACO) will...more

CMS Withdraws Medicare Secondary Payer Proposed Rule

The Office of Management and Budget (OMB) has withdrawn an Advanced Notice of Proposed Rulemaking (ANPRM) in which CMS planned to address how Medicare’s interest should be protected in situations where future medical costs...more

Medicare Shared Saving Program Interim Final Rule Extended

On October 17, 2014, the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services, Office of Inspector General (OIG) published in the Federal Register (79 FR 62356 et seq) a notice...more

CMS Provides for Greater MAC Involvement in ALJ Hearings

CMS recently issued Transmittal 543, Change Request 8501 in which it instructs Medicare Administrative Contractors (MACs) to, among other things, defend their medical review decisions through the Administrative Law Judge...more

Big Changes to Administrative Law Hearings for Medicare Providers

Effective October 27, 2014, the Medicare Program Integrity Manual (“Manual”) will require Medicare Administrative Contractors (“MACs”) to participate in administrative hearings concerning medical review decisions. ...more

Health Headlines: Also in the News - October 2014 #2

CMS Announces Changes to the Nursing Home Quality Rating System – On October 6, 2014, CMS announced upcoming changes to the nursing home five-star quality rating system. The changes include revising the scoring methodology...more

CMS Withdraws Proposed Medicare Secondary Payer Rule

On October 8, 2014, the Centers for Medicare & Medicaid Services (“CMS”) withdrew its Notice of Proposed Rule Making (“NPRM”) from the Office of Management and Budget that was to address how Medicare’s future interests should...more

Health Care Reform Implementation Update

In the past week, CMS has released several advisories including updates to the rating system for nursing homes, premium and deductible information for Medicare Part B and Part D for 2015, Pioneer ACO results, payment dispute...more

Critical Access Hospital Soothsayers and the 96-Hour Physician Certification Requirement

This year critical access hospitals (CAH) have struggled to implement procedures to comply with both the "two-midnight" rule and the 96-hour physician certification requirement. The combination of both puts physicians in a...more

CMS Issues 2013 RAC Report to Congress

On September 29, 2014, CMS released the Fiscal Year (FY) 2013 Recovery Audit Contractor (RAC) report. According to the report, RACs collected $3.65 billion in Medicare overpayments during FY 2013. In addition, the report...more

CMS to Modernize Home Health Regulations - Proposed rule targets quality of care, more flexible procedures

On October 9, 2014, the Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule revising current conditions of participation (CoPs) that home health agencies (HHAs) must meet in order to participate in the...more

CMS Offers To Settle All Acute Care Inpatient Claim RAC Appeals

CMS is offering to pay hospitals 68 percent of the allowable amount for all claims that are currently on appeal. Specifically, CMS is offering to settle "inpatient status" claims at 68 percent of the "net paid amount" within...more

FDA Regulatory and Compliance Monthly Recap - September 2014

In This Issue: - FDA sends warning letters to companies that made claims on social media that their products treat, cure Ebola, marking the first time the agency singles out Pinterest - OIG issues special...more

Today’s Riddle: When Does Medicare Fine Hospitals for Admitting Sick Seniors?

Give up? It’s when the sick senior was treated at that same hospital less than 30 days ago for heart attack, heart failure, or pneumonia. Starting in less than three months, the list of conditions will be expanded to cover...more

Medicare Enrollment: A Primer and How to Avoid Traps for the Unwary

Health-care professionals, facilities and equipment suppliers must be enrolled in the Medicare program to receive payment for covered items and services. In 2006, the Centers for Medicare & Medicaid Services adopted a...more

Health Headlines: Also in the News - September 2014 #4

CMS To Hold National Provider Call On Medicare Appeals Settlement Process – CMS has scheduled a “national provider call” on October 9, 2014, from 1:30 p.m. to 3:00 p.m. ET, to update providers on the global settlement...more

Blog: OIG Releases Proposed Rule re: Beneficiary Inducements and Gainsharing Revisions

The Health and Human Services Office of Inspector General (OIG) released today a proposed rule titled, Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors under the Anti-Kickback Statute, and...more

CMS Announces Launch of Open Payments Database: $3.5 Billion Paid to Physicians and Teaching Hospitals

The Open Payments database (the “Database”) is now live, and the first round of data is available to the public on the Centers for Medicare and Medicaid Services (“CMS”) website. This first round of data reflects “nearly 4.4...more

Audits and Appeals: A Routine Cost of Doing Business with Medicare

The Centers for Medicare and Medicaid Services has unleashed an alphabet of auditors to identify overpayments. These auditors are armed with the authority to conduct pre-payment reviews, and post-payment audits, as well as...more

Amid the Sunshine, Controversy Lingers: The Release of CMS's "Open Payments" System

In a March 2013 post on the Insider blog, we noted the issuance by the Centers for Medicare and Medicaid Services (CMS) of a long-awaited final rule mandating the collection of information regarding payments that drug and...more

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