News & Analysis as of

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

AHRQ Releases Guidance for Reductions in Medicaid Hospital Readmissions

The Agency for Healthcare Research and Quality (AHRQ) has issued a comprehensive guide with an interactive toolkit for providers to target reductions in Medicaid hospital readmissions. While numerous CMS initiatives have...more

How the US Government is cracking down on Medicare fraud

Medicare fraud is a major problem in the United States, with estimates of fraud and systematic overcharging totaling $60 billion each year. That’s nearly five times the cost of healthcare fraud in Canada, and makes up a...more

Who Audits the Auditors?

Since the advent of Medicare in 1965, hospitals have bemoaned the cost and burden of Medicare audits. The complaints increased when CMS hired private contractors for the audits. They became deafening in 2009 with the advent...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

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

CMS Publishes FY 2015 Final IPPS Rule

On August 4, 2014, CMS posted its final changes and updates to the Medicare Inpatient Prospective Payment System (IPPS) that apply for fiscal year (FY) 2015, effective October 1, 2014. Below are some of the highlights of the...more

Early Report on Value-Based Purchasing: Less to It Than Meets the Eye?

Medicare’s Value-Based Purchasing (VBP) program produced no improvement in either quality of care or patient satisfaction during its first nine months of operation. That’s the finding of a study led by Andrew Ryan, of the...more

Highlights from the Senate Special Committee on Aging’s Hearing on Medicare Observation Status

A recent Senate Special Committee on Aging hearing focused on the impact of Medicare observation status, a hospital outpatient designation for which Medicare covers fewer services and generally reimburses for services at a...more

Brace Yourself: The RACs Are Back

Under the controversial program private contractors audit hospitals and other Medicare providers for fraudulent and erroneous Medicare billing. Why is it controversial? Because the auditors are paid a percentage of...more

Impact on Medicare Payments of Shift in Site of Care for Chemotherapy Administration

Two independent trends, acting in combination, are currently resulting in increased Medicare fee-for-service (FFS) chemotherapy payments. The first trend is a shift in the site of care for cancer patients from physicians’...more

Does Medicare NOTICE Bill Miss the Point?

The bill would require hospitals to give meaningful notice to patients who have been assigned “observation” status for over 24 hours. Observation status is different from inpatient status under the rules of Medicare and other...more

The Probe and Educate Process For The Two-Midnight Rule

On August 2, 2013, the Centers for Medicare and Medicaid Services (“CMS”) released the final rule for the 2014 Medicare Inpatient Prospective Payment System (“IPPS”), effective October 1, 2013.[1] Introduced in the IPPS...more

Finally, Some Good News for Halifax–And All Other–Hospitals

It’s been a long time since Orlando’s Halifax Hospital got any good news from the federal court hearing the whistleblower case brought by employee Elin Baklid-Kunz. Earlier this year the hospital had to agree to an $85...more

Court Slams Medicare Agency, Notes Reputation As “Unfeeling Bureaucracy”

The Department of Health & Human Services’ Provider Reimbursement Review Board (Board) came in for some withering criticism last Friday from the federal court hearing the appeal of University of Chicago Hospital from the...more

Shorts on Long Term Care - Summer 2014

In this issue: - Nursing Facility Survey Trends: Directed Plans of Correction, Privacy Violations and FTag 520 Quality Assurance Committee Citations - COBRA Meets ACA – Time to Update COBRA Notices -...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

Is Off-Label Drug Promotion Protected Free Speech?

It is a very common practice. Drug sales reps visit a client, usually a hospital, a clinic or a doctor, with the sole purpose of selling a drug or medical device. That is the primary way a doctor learns about a drug or...more

Congress Sends Mixed Messages to Health Care Providers

Recent federal health care legislation sent mixed signals to health care providers. Pursuant to HR 4302, signed by President Obama on April 2, planned Medicare reimbursement cuts of 24 percent and the implementation of a...more

Teaching Hospitals and Physicians Must Take Action Now to Correct Erroneous Reports about them Submitted Under the Sunshine Act

On September 1, 2014, the Centers for Medicare and Medicaid Services (CMS) will make public the reports submitted by pharmaceutical and medical device manufacturers under the Sunshine Act. These reports will disclose...more

New Flexibility Under the Medicare Conditions of Participation: A Single Medical Staff Option for a Multi-Hospital System and...

As described in our prior alert, the Centers for Medicare & Medicaid Services (“CMS”) has, for the past several years, been seeking ways to reduce its regulatory burden on health care providers. In furthering this initiative,...more

D.C. Circuit Overturns PRRB’s Decision that Only Newly Built Hospitals Can Qualify for Favorable Capital Reimbursement Rates

In Select Specialty Hospital – Bloomington, Inc. v. Burwell, No. 15-5355 (D.C. Cir., Jul. 8, 2014), a group of long-term care hospitals (LTCHs) successfully challenged the Secretary’s determination that they were not “new...more

OIG Report Recommends Increased Scrutiny of Over 1000 Laboratories With Questionable Billing for Medicare Part B Clinical...

According to a recently released report by the HHS Office of Inspector General (OIG), over 1,000 labs had unusually high billing for Medicare Part B Clinical Laboratory Services for dates of service in 2010. Increased...more

Medicare Patients Caught In Two-Midnight Rule Crossfire

Hospitals have been complaining about the two-midnight rule since it was first announced. But mounting evidence indicates that Medicare patients themselves are suffering badly from the effects of the rule....more

Newly Released CMS Actuary’s Report Confirms CMS Ignored Impact of Two Midnight Rule on Medical Admissions When Setting 0.2...

On June 30, 2014, King & Spalding filed comments in response to Medicare’s proposed IPPS rule for Fiscal Year (FY) 2015 on behalf of more than 200 hospitals it represents in a federal court challenge to the FY 2014 Two...more

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