Physician Medicare Reimbursements

News & Analysis as of

House Passes SGR “Doc Fix” Legislation

On March 27, 2014, the House of Representatives passed H.R. 4302, which will postpone the scheduled 24% Medicare physician reimbursement cut by an additional one year. Several groups opposed the Bill as yet another temporary...more

Program Integrity Priorities Revealed in FY 2015 HHS Budget

On March 14, 2014, President Obama unveiled his Administration’s proposed fiscal year 2015 budget for the Department of Health and Human Services (HHS). In total, the Administration is seeking $77.1 billion to fund HHS in FY...more

Long Island Radiology Group Settles FCA Allegations That It Billed Medicaid And Medicare For Unnecessary Tests For $15.5M

A company operating diagnostic testing facilities in New York has agreed to pay $13.65 million to the federal government and $1.85 million to New York and New Jersey for a total of $15.5 million in penalties to settle claims...more

CMS Publishes DMEPOS Advance Notice of Proposed Rulemaking

On February 26, 2014, CMS published an Advance Notice of Proposed Rulemaking related to proposed changes to the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Medicare reimbursement methodologies. ...more

"Cursory Services" May Be "Worthless Services" Under False Claims Act

A recent federal court decision allowed the federal government to proceed with a False Claims Act (FCA) case involving an allegation that a health care provider’s “services were so cursory that they were worthless.” U.S. v....more

Health Care Reform Implementation Update - February 26, 2014

Though Congress was in recess this past week, congressional staff was hard at work continuing to consider ways to prevent a cut to Medicare providers’ payment rates that will be triggered by the sustainable growth rate...more

CMS Proposes Significant Rate Cuts and Other Changes to Medicare Advantage and Prescription Drug Plans

The Advance Notice ("Advance Notice") of Methodological Changes for Calendar Year ("CY") 2015 for Medicare Advantage ("MA") Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter was released by the Centers...more

Polsinelli Podcast - Health Care Payment Changes: From Service to Value [Video]

Healthcare is changing for consumers and providers under the Affordable Care Act. Less publicized is the way providers are now being paid and the way they will work together. In this week's Polsinelli "Inside Law," podcast,...more

CMS Issues New Policy on Disclosure of Physician Payment Information

On January 17, 2014, the Centers for Medicare & Medicaid Services (CMS) announced that it will release Medicare expenditure data on specific physicians under the Freedom of Information Act (FOIA). This new “transparency”...more

CMS – Doc, if You Want a Free Book Go to the Library

The Centers for Medicare and Medicaid Services (CMS) recently denied a request from a bipartisan group of 23 members of congress to exempt the distribution of textbooks and scientific peer-reviewed medical journal materials...more

HHS Issues Policy Regarding Physician FOIA Requests

On January 17, 2014, the Department of Health and Human Services (HHS) published its “Modified Policy on Freedom of Information Act Disclosure of Amounts Paid to Individual Physicians Under the Medicare Program” (the Modified...more

False Claim Act: 2013 Year in Review

Last year continued the trend of robust False Claims Act (FCA) enforcement by the U.S. Department of Justice (DOJ) and proliferating qui tam lawsuits brought by whistleblowers on behalf of the United States. In 2012, DOJ...more

Medicare Physician Fee Schedule Expands Telehealth Coverage in 2014

The Centers for Medicare & Medicaid Services (“CMS”) recently released the final rule for Medicare’s Physician Fee Schedule for 2014 Calendar Year (“CY). While physicians are expected to see a 20.1% reduction to their...more

CCME’s Prepayment Reviews Violate NCGS 108C-7!! Seriously!!

A few months ago I sent a public records request to the Division of Medical Assistance (DMA). I eventually received the information…today. I wanted to know how many providers had been put on prepayment review. ...more

President Obama Signs the Pathway for SGR Reform Act of 2013

On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking...more

CMS Issues Refunds For Collections Made On Incorrectly Identified Incarcerated Beneficiary Overpayments

Medicare does not cover supplies or services for persons who are incarcerated at the time the services are rendered. However, Medicare had purportedly paid providers in error for many such claims and sought to recover those...more

OIG Recommends that CMS Scrutinize Clinicians with High Cumulative Payments

Focusing on clinicians who receive high cumulative payments under Medicare Part B could be a useful means of identifying possible improper payments, according to a recent report issued by the Office of Inspector General of...more

Congress Moves Toward Permanent “Doc-Fix”

In a significant development, the House Ways and Means Committee and Senate Finance Committee each advanced its version of Sustainable Growth Rate reform legislation on Thursday, December 12. Thus, early next year, lawmakers...more

Health Care Fraud and Abuse Alert: What CMS’s New Billing Requirement For “Incident To” Services Means For Medicare Providers.

In the final Medicare Physician Fee Schedule for 2014 (“2014 PFS”), CMS implemented a new condition of payment for “incident to” services that has significant fraud and abuse implications for any Medicare provider who relies...more

2013 Healthcare Year In Review

Bob Dylan's quote from 1964 -- "The Times They Are A-Changin" -- could equally apply to the healthcare industry in 2013. This was the year that the Affordable Care Act ("ACA") came into full public view with the start of the...more

Health Reform + Related Health Policy News - October 2013

In This Issue: - Top News ..Judge Orders $237.4 Million Penalty Against Tuomey for Stark Law and False Claims Act Violations ..Glitches and Demand Lead to Marketplace Frustration ..HHS Delays Small...more

CMS Issues Proposed CY 2014 Medicare Physician Fee Schedule (MPFS) Rule and Suggests New Standars for Reimbursement of...

On July 19, 2013, CMS issued the proposed CY 2014 MPFS rule and suggested significant modifications to its regulations governing Medicare coverage of investigational devices and the routine items and services furnished to...more

Complex Chronic Care Management Reimbursement for 2015 Included in Proposed 2014 Physician Fee Schedule

The proposed 2014 Medicare Physician Fee Schedule [PDF] included reimbursement for case management to be made available in 2015 for physicians who treat patients with two or more complex conditions. The proposed rule would...more

Hospitals And Fraud Enforcement

The HHS Office of Inspector General has targeted hospitals for fraud enforcement. It is one of the OIG’s most important initiatives because of the impact it could have on reducing health care costs....more

Judge Approves Two-Year Delayed Prosecution of WakeMed

A Federal district court judge issued a February 8, 2013 order granting a delayed prosecution against Raleigh, NC-based WakeMed Health and Hospitals for allegedly submitting false inpatient bills to Medicare. The...more

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