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

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

Fraud and Abuse Waivers for MSSP ACOs Extended Another Year

Fridays are for fraud and abuse news-related releases, yet again. Last Friday, the HHS Office of the Inspector General (OIG) released a notice (Notice) informing the public that it has delayed the release of a final rule...more

Do You Offer or Accept Copayment Coupons? OIG says YOU are Responsible for Compliance with Federal Law

In recent years, copayment coupon programs have become standard promotional practices for both large and small pharmaceutical manufacturers. Copayment coupons are typically offered to commercially insured patients in order...more

Blurring the Lines between False Claims Act Litigation and Putative Federal Malpractice Law: The DOJ Quietly Invokes “Worthless...

On October 10, 2014, the United States Department of Justice (“DOJ”) announced a civil settlement agreement (the “Settlement”) with Extendicare Heath Services, Inc. and its subsidiary Progress Step Corporation (collectively,...more

Provider of Physical, Speech, and Occupational Therapy Services Agrees to $38,000,000 False Claims Act Settlement

As announced in an recent press release, Extended Care Health Services, Inc. (“Extendicare”), an operator of skilled nursing facilities, and its subsidiary Progressive Step Corporation (“Pro Step”), a provider of physical,...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

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

Seventh Circuit Reaffirms Worthlessness of Worthless Services Cases

In August the Seventh Circuit expressed its view that so-called “worthless services” cases don’t state a claim under the False Claims Act. Last Friday the court reaffirmed its view by refusing to rehear the case en banc....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

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

OIG Proposed Anti-Kickback Safe Harbors and CMP Regulations: The End of Frustration or Just the Beginning?

On October 3, 2014, the U.S. Department of Health and Human Services Office of Inspector General (OIG) published an unexpected, yet long-awaited, set of proposed rules that would add new anti-kickback law safe harbors,...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

Seniors Needn’t Drive into the City to Get Overcharged!

Remember when you had to drive into the city to get overcharged? Those days are over. According to a report issued Wednesday by the Office of Inspector General of Health & Human Services, Medicare patients pay two to six...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

Does the Medicare Telehealth Parity Act of 2014 Stand a Chance?

“Telehealth saves money and helps save lives. By expanding telehealth services, we can make sure the best care and the best treatments are available to all Americans, no matter where they live.” With those words, Rep....more

OIG Releases New Proposals on Anti-kickback Statute Safe Harbors, Exceptions to the CMP Law and the Gainsharing Prohibition

On October 3, 2014, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a long-awaited proposed rule for implementing amendments to safe harbors under the Anti-kickback Statute and...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

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

OIG Offers Greater Protections for Health Care Providers in New Proposed Rule

On October 3, 2014, the U.S. Department of Health and Human Services of the Office of Inspector General (OIG) issued a Proposed Rule amending both the safe harbors to the anti-kickback statute and the civil monetary penalty...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

Medicaid ACOs: States’ Answer to Escalating Costs?

States increasingly are experimenting with the use of Accountable Care Organizations (ACOs) in their Medicaid programs as a possible avenue to curb the escalating costs of providing care to expanding Medicaid populations....more

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