Provider Payments

News & Analysis as of

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

OIG Guidance Addresses Compliance Risks of Emerging Trends in the Healthcare Industry

The Office of Inspector General of the U.S. Department of Health and Human Services (OIG) recently released new compliance guidance to help healthcare governing boards, attorneys, compliance officers and internal auditors...more

Passage of the Bipartisan Budget Act: What You Should Not Do Now

Tips on preserving the provider-based status for existing clinics. The Bipartisan Budget Act of 2015 (H.R. 1314) was signed into law on Monday, November 2. Notwithstanding significant concerns raised by the hospital...more

Challenging Medicaid Prepayment Review

When the North Carolina Division of Medical Assistance (“DMA”) decides to place a Medicaid provider on prepayment review, it can be the equivalent of a death sentence for a small business. The primary problem is that there...more

CMS Not Implementing Changes to Miscellaneous DME Codes

CMS has announced that it will not adopt changes to miscellaneous durable medical equipment (DME) HCPCS codes on January 1, 2016, as it had proposed earlier this year in order to promote more accurate payment of DME claims....more

OIG Identifies Potentially Improper Medicare Ambulance Payments

In response to rising Medicare Part B payments for ambulance transports and continuing concerns about program vulnerabilities, the OIG has once again reviewed Medicare claims for ambulance services. The OIG estimates that...more

Uncertainty Continues for Two-Midnight Rule's Payment Reduction

In Shands Jacksonville v. Burwell [PDF], No. CV 14-1477, 2015 WL 5579653, (D.D.C. Sept. 21, 2015), the United States District Court for the District of Columbia gave the Secretary of the Department of Health and Human...more

OIG Recommends Reevaluation of Medicare Payment System for Skilled Nursing Facilities

The HHS Office of Inspector General (OIG) released a report on September 30, 2015 finding that Medicare payments for therapy services provided at skilled nursing facilities (SNFs) greatly exceeded the cost of such services. ...more

Primary Care Providers – Are You Feeling The Pinch?

It was nice while it lasted – due to a provision of the Patient Protection and Affordable Care Act (“ACA”), services furnished by certain primary care providers (“PCPs”) were subject to an enhanced payment rate for Calendar...more

CMS Releases Proposed Rule Reforming Medicare CLFS Payment Rates

The Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule [CMS-1621-P] in accordance with Section 216 of the Protecting Access to Medicare Act of 2014 (“PAMA”), which establishes a new payment methodology...more

Whistleblowers — and Taxpayers — Win Lawsuit over Medicare Fraud

Here’s another story with a satisfying ending and the take-home lesson that it’s a bad idea to cheat taxpayers and abuse medical resources. A chain of hospices agreed to settle a lawsuit over its overbilling of...more

CMS Publishes Final FY 2016 Update to SNF PPS Rates, Policies

On August 4, 2015, CMS published its final rule updating Medicare skilled nursing facility (SNF) PPS rates and policies for FY 2016. CMS projects that the final rule will increase overall payments to SNFs by $430 million, or...more

Provider Alleges Retaliatory Use of Medicare Payment Suspension

A federal court has ordered discovery regarding the circumstances of a Medicare payment suspension by CMS only one week after failed settlement negotiations between a cardiology practice and the Department of Justice (DOJ) to...more

Pennsylvania Hospitals Successfully Challenge Sequestration Reductions

In a case of first impression, a Pennsylvania court recently ruled in favor of 12 independent community hospitals (the “Hospitals”) that sued health insurer Highmark Inc. (“Highmark”) for passing on its 2 percent Medicare...more

D.C. District Court Formalizes Remand of Allina Case Regarding the Appropriate Treatment of Medicare Part C Patient Days for...

On May 18, 2015, the United States District Court for the District of Columbia ordered HHS to adjudicate the appropriate treatment of Medicare Part C patient days in determining disproportionate share hospital (DSH) payments....more

CMS Issues Proposed Rule Raising Hospice Provider Payments in FY 2016

On April 30, 2015, CMS issued a proposed rule that would give hospices serving Medicare beneficiaries an estimated 1.3 percent ($200 million) increase in their FY 2016 payments. Comments on the proposed rule are due by June...more

CMS Issues FY 2016 IPPS and LTCH Proposed Rule

On April 17, 2015, CMS released a proposed rule (Proposed Rule) to update the fiscal year (FY) 2016 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital...more

2016 Payment Notice and Final Call Letter: CMS Gives with One Hand and Takes Away with the Other

On April 6, 2015, the Centers for Medicare & Medicaid Services (“CMS”) issued the Announcement of Calendar Year (“CY”) 2016 Medicare Advantage (“MA”) Capitation Rates, and Medicare Advantage and Part D Payment Policies...more

Florida Bankruptcy Court Offers Potential Means to Stave Off Medicare Termination

A recent bankruptcy decision in Florida may have implications for troubled healthcare entities that seek to avoid Medicare termination and preserve reimbursements. ...more

OIG Examines CMS Payments to Hospitals for Clinic Visits

The HHS Office of Inspector General (OIG) estimates that CMS made $4.6 million in incorrect Medicare outpatient payments to hospitals for established patients’ clinic visits in 2012. ...more

CMS Announces Goals and Timeline for Shift to Value-Based Medicare Payments

On January 26, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a news release reporting Health & Human Services (HHS) Secretary Sylvia Burwell’s announcement earlier in the day of measurable goals and a...more

HHS Ups The Ante: Announces Percentages And Time Frames On Goals For Medicare Pay-For-Value Efforts

On January 26, 2015, the Secretary of the United States Department of Health and Human Services (“HHS”), Sylvia Mathews Burwell, announced two important goals for the Department...more

56 Results
View per page
Page: of 3

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:

Sign up to create your digest using LinkedIn*

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.