Provider Payments

News & Analysis as of

CMS's Proposed IPPS and LTCH FY 2017 Rule: Key Takeaways

On April 18, 2016, CMS released its proposed rule addressing new payment rates and policies under both the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS),...more

Yet Again, OIG Approves Medigap Policy Contracts with Preferred Hospital Network

On March 11, 2016, the U.S. Department of Health & Human Service, Office of the Inspector General (OIG) issued an advisory opinion approving the use of a preferred hospital network as part of Medicare Supplemental Health...more

Proposed Enrollment Rule Changes - de Facto Exclusion?

Proposed rules, touted as enhancing the provider enrollment process, would provide CMS with sanction authority that closely parallels the OIG’s exclusion authority. Under the proposed rules, CMS would have expanded bases to...more

MedPAC Publishes Report to Congress on 2017 Policies, Recommends Payment Reforms and Cuts to Part B Payments to Hospitals for 340B...

On March 15, 2016, MedPAC submitted its 2016 annual report to Congress on Medicare payment policies for 2017. In the Report, MedPAC makes a number of recommendations to Congress pertaining to payment under Medicare...more

Drug Company Payments and Prescribing Patterns Linked, Massachusetts Is An Outlier

As reported in yesterday’s Boston Globe, compared to national averages, Massachusetts physicians are less likely to receive payments or items of value from pharmaceutical companies and less likely to be heavy prescribers of...more

Court Allows 'Retroactive' Application of 2005 Wage Index Rule Limiting Reimbursement for Pension Plan Costs

On February 22, 2016, in Regents of the University of California v. Burwell, the U.S. District Court for the District of Columbia granted summary judgment in favor of the Secretary of Health and Human Services (the Secretary)...more

MedPAC Report Recommends Reduction in Medicare Part B Payments to 340B Hospitals

On March 15, 2016, the Medicare Payment Advisory Commission (MedPAC) released its latest report to Congress that included 340B Implications for Medicare Part B Drugs along with a quick fact sheet regarding the report. Key...more

CMS Issues Proposed Medicare Part B Drug Payment Model

On March 11, 2016, CMS published in the Federal Register its proposed new Medicare Part B Drug Payment Model. Comments are due by May 9, 2016. Below are some highlights of the proposed rule....more

Also In The News - Health Headlines - March 2016

OMB to Review Medicare Appeals Procedures – The Office of Information and Regulatory Affairs (“OIRA”) within the Office of Management and Budget (“OMB”) is set to review new Medicare appeals process proposed rulemaking. ...more

Program Integrity Changes to the Medicare Provider Enrollment Process

On March 1, 2016, the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) entitled “Medicare, Medicaid, and Children’s Health Insurance...more

CMS Issues Notice of Benefit and Payment Parameters for 2017

On February 29, 2016, CMS issued the final annual Notice of Benefit and Payment Parameters for the 2017 coverage year (“Final Notice”), along with related guidance documents. The Final Notice sets standards for issuers and...more

Outpatient Therapy Providers - Location Matters

Included in its publication announcing changes for outpatient therapy services in the 2016 Medicare Physician Fee Schedule (MPFS), CMS announced a new requirement for Medicare-certified outpatient therapy providers (e.g.,...more

FDA Gauges Coverage Organizations’ Interest in Connecting with Device Sponsors to Discuss Evidence Needs During Clearance Process

The FDA published a notice on February 24, 2016 requesting whether organizations (e.g. insurers, health technology assessment organizations) that evaluate clinical evidence used to support private payer medical device...more

CMS Announces Collaborative Core Quality Measures

CMS, in a collaboration with American’s Health Insurance Plans (AHIP), announced on February 16, 2016, seven sets of “core measures” to align quality measures required for physician reporting. These core measures align the...more

Groundbreaking Multi-Payer Alignment on Core Measures for Quality-Based Payments

For too long, health industry stakeholders have bandied about massive amounts of information that could not be used in a comparative sense. Both public and private payers had their own proprietary reporting metrics,...more

Health Update - January 2016

The Megatrends Reshaping Healthcare: Managing Change and Maximizing Opportunity - Editor's Note: In 2013, Manatt Health identified 10 megatrends that would reinvent the healthcare marketplace across the next decade. In a...more

2-Midnight Rule Updates

- CMS Adopts Change to Benchmark and Shift in Enforcement - CMS Explains Reasoning Behind 0.2% Payment Reduction CMS has published discussions of the 2-midnight rule in two recent Federal Register publications. In the...more

CMS Finalizes Prior Authorization Program for Certain DMEPOS Items

On December 30, 2015, the Centers for Medicare & Medicaid Services (CMS) published its final rule establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)...more

The Managed Care Industry – 2015 Year in Review

As we start a new year, let’s take a look back at a few hot topics that emerged in the managed care industry in 2015 and will likely be drivers of developments in 2016. Industry Consolidation – The Changing Landscape...more

GAO Recommends Payment Reform in Response to Increase in Hospital/Physician Consolidation

On December 18, 2015, the Government Accountability Office (GAO) released a report analyzing the increase in hospital/physician consolidation and a related increase in Medicare hospital outpatient spending. Finding that...more

A&B Healthcare Week in Review, November 2015

I. REGULATIONS, NOTICES, & GUIDANCE - On November 21, 2015, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule entitled “Patient Protection and Affordable Care Act; HHS Notice of Benefit and...more

CMS Publishes Final Rule on Medicaid Fee-For-Service Ratesetting for Assuring Access to Covered Medicaid Services

On November 2, 2015, CMS published a final rule with comment period that is intended to provide a transparent, data-driven process for states to follow when they set Medicaid provider payment rates, effective January 4, 2016....more

Congress Enacts "Provider-Based" Surprise

Hospitals have long tried to expand their footprints by developing, or in many instances acquiring, physician practices and other medical operations to provide services beyond the immediate vicinity of the hospital’s campus....more

CMS Issues CY 2016 Final Rule for Hospital Outpatient and Ambulatory Surgical Center Policy and Payment Changes

On October 30, 2015, CMS issued its final policy changes, quality provisions and payment rates for the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for...more

Health Care Group News: Bi-Partisan Budget Act Affects New Provider-Based Facilities

On October 30, 2015 Congress passed the Bi-Partisan Budget Act of 2015 (hereinafter the "Act"). Section 603 of the Act is of particular relevance to hospitals and health care providers because of its potential to chill the...more

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