Patient Prospective Payment System

News & Analysis as of

Washington State Court Recognizes Prospective Patient Relationships as Protected Contracts

42 U.S.C. § 1981 prohibits discrimination affecting citizens rights to make contracts. In the credentialing field, § 1981 has been used to circumvent the immunities provided by the Health Care Quality Improvement Act (HCQIA)...more

Highlights of the 2015 Home Health Prospective Payment Rule

On November 6, 2014, CMS published its final Medicare home health prospective payment system (HH PPS) rule for calendar year (CY) 2015. As highlighted below, notable changes in the HH PPS final rule [PDF] include: (1) a...more

Representative Brady Introduces Discussion Draft of the Hospital Improvements for Payment Act of 2014

On November 19, 2014, House Ways & Means Health Subcommittee Chairman Kevin Brady introduced a 146-page discussion draft of the Hospital Improvements for Payment Act of 2014 (HIP). HIP seeks to, among other things, make...more

Highlights of the 2015 OPPS and ASC Final Rule

On October 31, 2014, CMS published its 2015 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates final rule. This annual rule affects the 4,000...more

CMS Finalizes Several Changes for Skin Substitutes in CY 2015 Outpatient Prospective Payment System Final Rule

On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released its annual final rule (Final Rule) setting the payment rates and coverage policies for items and services reimbursed under the Outpatient...more

CMS Finalizes 2015 Home Health Prospective Payment System Rule

The Centers for Medicare & Medicaid Services (CMS) published the annual final rule on the Medicare home health prospective payment system (HH PPS) rates for calendar year (CY) 2015 in the November 6, 2014, Federal Register...more

CMS Announces CY 2015 Home Health Prospective Payment System Rates

On October 30, 2014, CMS issued a final rule for Medicare Home Health Prospective Payment System (HH PPS) rates for CY 2015. The final rule estimates that Medicare payments to home health agencies (HHAs) in CY 2015 will be...more

CMS Reopens Open Payments System, Extends Review/Dispute Period and 15-Day Correction Period

On Friday, August 15, 2014, CMS officially announced the reopening of its Open Payments system and an extension of the covered recipient review/dispute period and subsequent data correction period. Our understanding is that...more

CMS Proposes Update to 2015 Home Health Prospective Payment System for Comment

The Centers for Medicare & Medicaid Services (CMS) published its proposed update of the Medicare home health prospective payment system (HH PPS) rates for calendar year (CY) 2015 in the July 7, 2014 Federal Register. In...more

Medicare's Proposed Home Health Rule for 2015: CMS Suggests Only Limited Relief to the Face-to-Face Encounter Documentation...

On July 7, 2014, the Centers for Medicare & Medicaid Services ("CMS") published proposed changes to the Medicare Home Health Prospective Payment System ("HH PPS") for calendar year 2015 ("Proposed Rule"). The Proposed Rule...more

Federally Qualified Health Centers: Welcome to PPS

CMS recently finalized a new PPS for Federally Qualified Health Center (FQHC) services. The implementation of the PPS was mandated by the ACA. Medicare currently pays FQHCs an all-inclusive rate for the professional...more

CMS Expands Payment Reform to Outpatient Care in New RFI

Citing the need to complement a portfolio of pilot projects that focus mostly on primary care and the inpatient setting, CMS released a Request for Information (RFI) on February 11th, seeking input on potential payment and...more

MedPAC Issues Draft Recommendations For 2015 Medicare Payments

The Medicare Payment Advisory Commission (MedPAC) met on December 12-13, 2013, to discuss draft recommendations regarding 2015 payment updates for Medicare providers. MedPAC, which is responsible for issuing an annual...more

CMS "Packages" Clinical Laboratory Tests Into Outpatient Prospective Payment System

Hospitals Lose Right to Bill Separately for Laboratory Tests for Outpatients - As part of its calendar year 2014 hospital outpatient prospective payment system (OPPS) policy changes, the Centers for Medicare & Medicaid...more

CMS Outpatient and Physician Payment Rules: Don't Miss the Efficient Quality of Care Reform Forest for the Dollar Trees

The final physician fee schedule (PFS) and hospital outpatient department payment rules for FY 2014 clearly signal the continued intent by the Centers for Medicare and Medicaid Services (CMS) to transform the healthcare...more

CMS Releases CY 2014 Hospital OPPS and ASC Final Rule

CMS has published its Calendar Year (CY) 2014 Final Rule for Medicare policy and payment rates for hospital outpatient prospective payment systems (OPPS) and Ambulatory Surgical Center (ASC) services. This final rule with...more

Publication of Home Health Prospective Payment System Final Rule

On December 2, 2013, the Federal Register published CMS’s final rule regarding the home health prospective payment system (PPS) and home health quality reporting requirements. The final rule reduces payments under the PPS by...more

CMS Announces New Cost Reporting Procedures to Address DSH Uncompensated Care Payments

In the fiscal year 2014 Inpatient Prospective Payment System (IPPS) rule (the “final rule”), CMS explained the new disproportionate share hospital (DSH) payment methodology that took effect this October 1. As we reported in...more

CMS's Two-Dog Night - Doctor Told Me Not to Stay as an Inpatient for Less Than Two Nights

The Centers for Medicare and Medicaid Services (CMS) recently issued controversial new criteria for hospitals to use to determine whether a patient's stay in a hospital should be treated as an outpatient observation stay or...more

FY 2014 IPPS/LTCH PPS Final Rule Goes Into Effect October 1, 2013

In This Issue: - What Providers Should Know - Requirements for Inpatient Admissions and Payment Under Medicare Part A - New Rules Permitting Re-billing Under Medicare Part B for Denied Admissions - New HAC...more

Federal District Court Rules Against Medicare Beneficiaries Challenging Observation Status

In Bagnall v. Sebelius, No. 3:11-CV-01703 (D. Conn.), a federal district court in Connecticut recently granted a motion to dismiss the complaint of fourteen Medicare beneficiaries seeking to invalidate an HHS policy allowing...more

Three-Month Implementation Period for “Two-Midnight” Rule to Begin October 1, 2013

CMS issued guidance on September 26, 2013, regarding the implementation of the “Two-Midnight” rule addressed in the August 2013 Inpatient Prospective Payment System (IPPS) final rule. Under the Two-Midnight rule, patient...more

CMS Issues Inpatient Admission Order and Certification Guidance

On September 5th of this year, CMS issued guidance [PDF] addressing hospital inpatient admission orders and certifications. The regulations addressing certifications at 42 C.F.R. §§ 424.13 – 424.16 were revised as part of the...more

CMS Issues Guidance Concerning Inpatient Admission Order and Certification Requirements

On September 5, 2013, CMS issued guidance concerning its new inpatient admission order and certification policies. As previously reported, CMS adopted new policies governing inpatient admissions, including inpatient...more

2-Midnight Inpatient Admission Policy

Under CMS’s modified inpatient admission guidelines adopted in the IPPS Final Rule, Part A payment is “generally inappropriate” unless the patient is admitted based on the physician’s expectation that the patient will require...more

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