News & Analysis as of

Provider Payments

CMS Releases the Proposed Part D DIR Reporting Requirements for 2016

Yesterday, CMS released the Proposed Part D DIR (Direct and Indirect Remuneration) Reporting Requirements for 2016 and postponed the 2016 DIR Reporting deadline....more

CMS Proposes to Eliminate Therapy-Driven SNF Reimbursement

by Baker Ober Health Law on

It should come as no surprise to anyone working with skilled nursing facilities (SNFs) that CMS has been exploring ways to adjust its current payment model to reduce or eliminate skilled therapy utilization as the primary...more

Proving Utility, Demonstrating Value: How to Align the Moving Parts in Personalized Medicine Reimbursement

by Foley & Lardner LLP on

Of the many business, operational, legal, regulatory and clinical obstacles standing in the way of widespread delivery of personalized medicine, the single greatest challenge may lie in solving the reimbursement puzzle....more

Delayed ETA for EPMs – CMS Delays New Bundled Payment Models

by Baker Ober Health Law on

On March 21, 2017, CMS issued the anticipated delay related to the new Episode Payment Model (EPM) bundled payment program regulations that were finalized in January. The rule, Advancing Care Coordination Through Episode...more

Percentage-Based Billing Contracts Violate Medicaid Regulations and May Constitute Improper Fee-Splitting

by Farrell Fritz, P.C. on

The Medicaid Fraud Control Unit (MCFU) of the New York State Office of the Attorney General has recently issued restitution demand letters to providers for allegedly entering into percentage-based contracts with their billing...more

New York Medical Society Warns Providers to Avoid Percentage-Based Billing

A series of recoupment letters from the New York State Medicaid Fraud Control Unit (MFCU) to healthcare providers who have management or billing company arrangements based on a percentage of collections has prompted the...more

Payor/Provider Convergence: Joint Venture Health Plans

by Foley & Lardner LLP on

Health Plans and health care providers are getting into each other’s business. This payor/provider convergence has taken different forms. Health systems have ventured into the health insurance business by acquiring or...more

Provider Payments Under a Medicaid Per Capita Cap

In a February 24th blog post, we described Medicaid block grants and per capita caps in terms of A x B = C to demonstrate how those payment policies work. ‘A’ is the amount a state is paid per beneficiary, ‘B’ is the number...more

White House “Regulatory Freeze” Delays Implementation of Bundled Payment Models

by King & Spalding on

In the February 17, 2017 Federal Register, CMS announced that it will delay implementation of several bundled payment initiatives until March 21, 2017. The Advancing Care Coordination Through Episode Payment Models (EPMs),...more

Recent Changes to Medicare “Incident To” Billing Rules

by Ruder Ware on

Medicare permits a physician to bill for certain services furnished by a nurse practitioner or other auxiliary personnel under what is referred to as the "incident to" billing rules. The "incident to" rules permit services...more

Medicare Mandatory Bundled Payments Rule: Minor Aspects Delayed, Others On-Schedule for July Implementation

by Polsinelli on

In a move the Centers for Medicare & Medicaid Services cites as a reaction to President Donald Trump's regulatory freeze, CMS announced that implementation of certain minor aspects of the final rule expanding Medicare...more

New Bundled Payments Are a Go…For Now

by Baker Ober Health Law on

CMS issued a final rule on January 3, 2017, implementing three new episode payment models (EPMs) and a Cardiac Rehabilitation (CR) incentive payment model under the authority of the Center for Medicare & Medicaid Innovation...more

Big Changes and Uncertainty Looming for Off-Campus Provider-Based Departments

by Alston & Bird on

Originally posted in Bloomberg BNA’s Medicare Report, 28 MCR 96, 2/3/17. On November 1, 2016, the Centers for Medicare & Medicaid Services (CMS) released the Hospital Outpatient Prospective Payment System (HOPPS) - Final...more

Governor Kasich Releases $144 Billion State Budget Proposal - What You Need to Know

by Roetzel & Andress on

Yesterday, Governor Kasich released the executive version of the state’s two-year operating budget (Fiscal Years 2018-2019), which includes proposed spending of over $144 billion during the biennium. Similar to his previous...more

The Brave New World of Physician Medicare Payment: MACRA Makes Sweeping Changes

by Seyfarth Shaw LLP on

On November 14, 2016, CMS published its final rule implementing the physician payment provisions of the Medicare Access and CHIP Reauthorization Act (“MACRA”). The rule became effective January 1, 2017. Data collection from...more

CMS Finalizes Tighter Rules for New Medicaid Managed Care Pass-Through Payments

by Reed Smith on

CMS has finalized without change its proposed rule to block states from adopting or increasing Medicaid managed care “pass-through” payments to hospitals, nursing facilities, and physicians beyond those in place when...more

Healthcare Transactions: Year in Review - January 2017

by Bass, Berry & Sims PLC on

Healthcare transactional activity continued unabated throughout 2016, continuing a years long trend of sustained growth. This activity is due to a number of factors: innovative technology, pharmaceuticals, and services that...more

Final Rule Implements Quality Payment Program under MACRA

by Baker Ober Health Law on

If you are a physician, mid-level provider, or work with those providers, then you have been bombarded with new acronyms for new programs and promises to remove older acronyms from your Medicare vocabulary. Medicare...more

The 21st Century Cures Act

by Baker Ober Health Law on

Signed into law by President Obama on December 13, 2016, the 21st Century Cures Act (Act) was overwhelmingly supported in both houses of Congress and comprises a dizzying array of provisions aimed to improve and modernize...more

U.S. District Court for District of Columbia Requires HHS to Eliminate Medicare Appeals Backlog by December 31, 2020

by Baker Ober Health Law on

On December 5, 2016, a U.S. District Court for the District of Columbia granted summary judgment in American Hospital Association, et al., v. Burwell, in favor of the American Hospital Association (AHA) in its quest to reduce...more

21st Century Cures Act Provides Some Welcome Relief

by Foley & Lardner LLP on

The 21st Century Cures Act (the “Cures Act”) (Pub. L. No. 114-255), which was signed into law by President Obama on December 13, 2016, includes a number of important health care provisions, and several address the...more

OIG Still Rejects Lab's Free Labeling Services for Dialysis Facilities in Advisory Opinion No. 16-12

by Baker Ober Health Law on

8 Years and New Reimbursement Methodology Later - On November 28, 2016, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) issued an unfavorable advisory opinion, No. 16-12, regarding a...more

CMS Final Rule and 21st Century Cures Act Include Good and Bad News for Provider-Based Sites

by Baker Ober Health Law on

CMS recently published its final outpatient prospective payment system (OPPS) rule, which includes its new policies governing payment related to services furnished at off-campus provider-based departments (OPBDs). 81 Fed....more

2016 Health Care Year in Review

by Burr & Forman on

Since I began writing this year-end review in 2013, there have been some common themes – a shift to pay for quality and away from fee-for service, much of which has been brought about by the Affordable Care Act (ACA): efforts...more

New POS Code for Telehealth Distant Site Providers

by Baker Ober Health Law on

A new Place of Services or POS code for Telehealth services (POS 02) will go into effect on January 1, 2017. The descriptor for the code, which is for use by the physician or other clinician furnishing telehealth services...more

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