News & Analysis as of

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

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

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

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

Medicare Bundled Payments Initiative and Oncology Care

According to Modern Healthcare’s “Interest Surges in Medicare Bundled Payment Initiative” article on July 31, 2014, enthusiasm for bundled pricing has been associated with the Medicare Bundled Payments for Care Improvement...more

Telehealth and Health IT Policy: Considerations for Stakeholders

In recent months, as the conversation about reforming the health care system has shifted to achieving greater delivery system efficiencies, cost containment, and patient satisfaction, the role of health care...more

Medicare Increases Coverage of Mental Health Services

Medicare has increased the amount of mental health coverage beneficiaries are entitled to. After years of unequal treatment, Medicare now covers mental health care the same way it covers physical illnesses....more

CMS Says: Let's Make a Deal

In the hours before everyone began enjoying Labor Day Weekend, the Centers for Medicare & Medicaid Services (CMS) issued an important inpatient hospital review update....more

CMS Issues Final Rule for Inpatient Stays in Acute Care and Long Term Care Hospitals

On August 1, 2014, the Centers for Medicare and Medicaid Services (CMS) issued its annual final rule for policy and payment changes applicable to inpatient stays in acute care and long term care hospitals (Final Rule). This...more

News from the Health Law Gurus™

2019 Medicare Budget Reduced by $95 Billion – The New York Times is reporting that the projected Medicare budget for 2019 is $95 billion less than the projected budget for 2019 four years ago. According to the...more

CMS Makes Global Offer to Settle All Acute Care Inpatient Claims on Appeal

On August 29, 2014, CMS issued settlement terms to acute care hospitals with pending appeals of denials for inpatient claims. CMS is offering to settle all qualifying claims at 68 percent of the “net paid amount” of such...more

Seventh Circuit Limits “Worthless Services” Theory under False Claims Act

On August 20, 2014, the Seventh Circuit struck another blow against relators’ and the federal government’s increasingly aggressive False Claims Act theories of liability. Rejecting the relators’ use of the “worthless...more

OIG Okays Medigap Insurer’s Arrangement for Discount on Inpatient Deductibles

Last Monday the Office of Inspector General (OIG) of Health & Human Services posted an advisory opinion (No. 14-07) allowing a Medigap insurance company to strike a deal with hospitals for discounts—even waivers—of the...more

Health Care: Charting the Path Forward to DSRIP for Long-Term Care Providers (8/14)

Designed by New York State to seek a federal waiver for the expenditure of Medicaid funds, the Delivery System Reform Incentive Program (DSRIP) will allocate 6.42 billion dollars to health care providers in New York State to...more

Veterans Access, Choice, and Accountability Act May Result in More Patients for Medicare Providers

The President signed the Veterans Access, Choice, and Accountability Act of 2014 [PDF] on August 7, 2014 (the “Act”). Ordinarily, the Department of Veterans Affairs (VA) provides medical care to veterans at Veterans Health...more

FDA to Strengthen Oversight of Certain In Vitro Diagnostic Devices

In the wake of a new Medicare reimbursement framework, FDA plans stricter regulation of some in vitro diagnostic devices. On July 31, 2014, the U.S. Food and Drug Administration (FDA; Agency) announced its intent to...more

Research Doesn’t Pay—At Least Not in Graduate Medical Education

Indirect graduate medical costs, or IGME, are what Medicare allows teaching hospitals in increased Medicare rates. IGME represents the indirect costs to a teaching hospital of hosting residents and interns—costs above and...more

GAO Concludes CMS Should Increase Oversight of Post-Payment Claims Review Process

The Government Accountability Office (GAO) has released the findings of its study of the steps taken by CMS to prevent Medicare contractors from conducting certain duplicative post-payment claims reviews. Based on its audit,...more

CMS Care Coordination Payments – A Boon to Doctors and Patients but Patient Participation Will be Essential

As the Affordable Care Act continues to mature, we are seeing new efforts by the Obama administration to incentivize care coordination across a spectrum of services provided to Medicare Fee-for-Service (FFS) patients. A New...more

Government Sues Hospital for Birthing Mama’s Babies

The Clinica de la Mama case could well serve as an instruction manual of what not to do to stay out of the government’s crosshairs. In this case, several hospitals entered into contracts for Clinica de la Mama to provide...more

Limited Restart of RAC Program

On August 4, 2014, CMS announced that, due to the continued delay in awarding new Recovery Audit Contractor (RAC) contracts, CMS will modify its current RAC contracts to allow for a limited number of reviews of Medicare...more

Federal Court Rejects Relator’s Swapping Allegations in False Claims Act Case

This week a federal district court in Ohio ruled in favor of Mobilex USA (Mobilex), the country’s largest mobile medical imaging company, on a motion for summary judgment in a False Claims Act (FCA) suit filed by a former...more

Unnecessary Surgeries Put Hospital in Three-Front War

When the government accuses a hospital of committing Medicare fraud by billing for unnecessary surgeries, the hospital has a real problem on its hands. It’s at war with the government, and that’s expensive, as well as...more

HHS Enjoined from Enforcing Self-Disallowance Regulation

On August 6th, the U.S. District Court for the District of Columbia enjoined HHS (along with the PRRB and CMS’s Medicare contractors) from applying HHS’s “self-disallowance” regulation to any appeals filed on the basis of an...more

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