News & Analysis as of

CMS Proposes Changes to Sunshine Act Reporting

Drug and device manufacturers breathing a sigh of relief after completing their 2013 data submissions under the Physician Payment Sunshine Act (the “Sunshine Act’) must now contend with four proposed changes to the Sunshine...more

OIG: Medicare Inappropriately Paid for 2010 E/M Services Claims - Physicians should expect higher scrutiny on Medicare claims...

Inspector General Daniel R. Levinson with the Office of the Inspector General (“OIG”) recently issued a startling report explaining that Medicare inappropriately paid $6.7 billion for claims for E/M Services in 2010. These...more

Risk Taking in the Provider World: Is a Knox-Keene Plan a Good Strategic Move For You?

Reimbursement for health care services in California continues its shift toward capitation, resulting in health care providers increasingly forming their own health plans under the Knox Keene Health Care Service Plan Act (the...more

Cloudy Skies Ahead for Providers? CMS’ Release of Medicare Billing Data Combined with Physician Payment Sunshine Act Data May...

In February 2013, we reported (on our Healthcare Law Blog) that the Centers for Medicare and Medicaid Services (CMS) announced the final rule for the Physician Payments Sunshine Act. In the interest of providing more...more

AMA To Recommend Physicians Be Paid For End-Of-Life Planning

Brace yourself for a reprise of the death panel debate of 2009. The AMA will soon formally recommend to CMS that physicians be paid—or “reimbursed” in health care-speak—for talking with Medicare patients and their families...more

Quantifying and addressing improper payments for Medicare evaluation and management services

A review of Medicare Part B claims for evaluation and management (E/M) services conducted by the Office of the Inspector General (OIG) has found that the program paid $6.7 billion in improper payments in 2010. This figure...more

How Are Your Physicians Compensated? Stark Law + False Claims Act = Halifax Paying $85 Million

On March 10, 2014, just days before trial, Halifax Hospital Medical Center and Halifax Staffing, Inc. (collectively “Halifax”) entered into an $85 million settlement with the U.S. Department of Justice resolving allegations...more

Recent OIG Report Underscores Need for Home Health Agencies and Physicians to Comply With Medicare’s Face-to-Face Documentation...

Medicare overpaid the home health industry $2 billion between January 2011 and December 2012, according to a recent report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG). The OIG’s...more

Transgender Woman Seeks Coverage Under ACA

A transgender woman recently filed a complaint in the U.S. District Court for the Central District of Illinois against her primary care physician, as well as the not-for-profit health-care clinic with which her physician is...more

Health Law Wire: Physician Medicare Revalidation Notice

On January 29, 2014, the National Government Services, Inc. announced that it would begin mailing out revalidation notices (“Notice”) to physicians enrolled in the Medicare program sometime in the next (12) months. Physicians...more

CMS Advised to Follow Private Sector Practices to Improve Physician Feedback Reports

On March 26, 2014, the Government Accountability Office (GAO) released its report regarding the private sector’s physician feedback reporting practices and how implementation of such practices could improve CMS’s own reports...more

When It Comes to Medicare Payment, Physicians Have Choices

Health care providers can choose to enroll in, participate in, or opt out of Medicare, but… - Not everyone can choose equally and their choices will net direct outcomes in their practice income. Medicare jargon can be...more

CMS authorizes contractors to deny ‘related’ claims of physicians who are not undergoing review

The Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services recently issued Transmittal 505 modifying Section 3.2.3 of the Medicare Program Integrity Manual. CMS employs a variety of...more

Joint SGR Repeal Bill Agreed Upon, Moving to Full Congress

New joint legislation to repeal Medicare’s failed SGR formula is advancing to both chambers of Congress following an agreement announced Thursday by the three committees that put forth repeal bills earlier this...more

Funding Offsets Proposed for Physician Payment Overhaul

Congressional lawmakers are currently reviewing 65 potential funding offsets for legislation that would overhaul the Medicare physician payment system. In its present form, Medicare’s sustainable growth rate (SGR) formula...more

Also in the News

President Obama Signs Pathway for SGR Reform Act of 2013 – On December 26, 2013, President Obama signed the Pathway for SGR Reform Act of 2013 (the “Act”), preventing the scheduled payment reduction for...more

SGR-Driven Payment Reduction Postponed Again

As part of the Balanced Budget Act of 1997 (BBA), Congress enacted a number of payment reforms designed to curb the growth of expenditures under Medicare Part B. One of the more notable of those provisions was the Sustainable...more

Congress Passes 3 Month SGR Reprieve: .5% Medicare Physician Increase

The AMA Wire reports action on the Medicare Physician Fee Schedule. The payment increase staves off a 24 percent cut required by the failed SGR formula and buys three months for Congress to complete its work on SGR repeal...more

Judge Issues Preliminary Injunction Barring UnitedHealthcare from Terminating Certain Physicians From Medicare Advantage Plans

The United States District Court for the District of Connecticut recently granted Fairfield County Medical Association’s and Hartford County Medical Association’s (collectively, the “Associations”) motion for a preliminary...more

CMS Announces Plans to Modernize and Update the Clinical Laboratory Fee Schedule

On November 27, 2013, Centers for Medicare & Medicaid Services posted the final 2014 Medicare physician fee schedule and, in it, announced plans to change how and how much Medicare pays for clinical diagnostic laboratory...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

CMS Releases Final Rule for 2014 Medicare Physician Fee Schedule

CMS has released its much-anticipated final rule with comment for the Calendar Year (CY) 2014 Medicare Physician Fee Schedule (PFS). The final rule prescribes physician payment rates that will go into effect on January 1,...more

CMS Issues Medicare Physician Fee Schedule Final Rule

On November 27, 2013, CMS released a 1,369 page display copy of the CY 2014 Medicare Physician Fee Schedule (PFS) final rule. The final rule, which was delayed because of the government shut-down in October, is scheduled to...more

CMS Issues Medicare Physician Fee Schedule Without Finalizing Proposal Most Harmful to Independent Laboratories

On the day before Thanksgiving and a little over one month after the end of the government shutdown, the Centers for Medicare & Medicaid Services (“CMS”) published a rule finalizing revisions to payment policies under the...more

Bonuses for Physician Employees: Lessons Learned from the Halifax Hospital Case

This week, a federal district court in Florida concluded that a hospital violated Stark as a matter of law by entering into employment agreements with physicians that included bonus compensation that was not based exclusively...more

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