News & Analysis as of

Is Provider-Based Reimbursement Going Away?

We get this question every year: will Medicare, Medicaid or other payors continue to recognize hospital-level facility fee reimbursement for hospital outpatient departments meeting the provider-based designation criteria at...more

FDA to Strengthen Oversight of Certain In Vitro Diagnostic Devices

In the wake of a new Medicare reimbursement framework, FDA plans stricter regulation of some in vitro diagnostic devices. On July 31, 2014, the U.S. Food and Drug Administration (FDA; Agency) announced its intent to...more

Friday Afternoon Smackdown – The SEC v. The House Of Representatives

On Friday, June 20, 2014, the Securities and Exchange Commission filed an action against the Committee on Ways and Means of the U.S. House of Representatives and congressional staffer Brian Sutter seeking enforcement of...more

Healthcare Providers Face Increasing Financial Pressure and Bankruptcy Risk

The health of the healthcare industry can be summarized as follows: as go federal reimbursement rates, so goes the financial viability of healthcare providers, whether hospitals, nursing homes or medical practices. These...more

HHS Proposes Extension of Deadline for EHR Compliance

According to the federal government, over 370,000 providers have participated in the Medicare and Medicaid Electronic Health Record ("EHR") incentive program since its inception in 2011. However, providers nationwide continue...more

CMS Announces Proposed SNF Reimbursement Rates for FY2015

On May 1, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would include payment and policy changes for skilled nursing facilities (SNFs) (Proposed SNF Rule). The Proposed SNF Rule would...more

Medicare’s 60-Day Proposed Refund Rule Imposes Significant Liability on Providers

As part of the Affordable Care Act, Congress outlined the process for providers to return Medicare and Medicaid overpayments. In 2012, CMS proposed the 60-day Refund Rule, as it is commonly known, requiring Medicare providers...more

CVS Caremark Pays $4.25 Million to Settle False Claims Allegations

Earlier this month, Caremark Incorporated – a drug benefit management company operated by drug retail giant CVS Caremark Corporation –agreed to pay $4.25 million to settle allegations that it knowingly failed to reimburse...more

Ninth Circuit Vacates Injunctions Barring HHS From Seeking Prepayment of Medicare Secondary Payer Reimbursements

The United States Court of Appeals for the Ninth Circuit recently vacated injunctions entered by a district court that banned HHS from seeking “up front” reimbursements for Medicare secondary payments from beneficiaries who...more

CMS's Use of Contractors to Determine "Sustained or High Level of Payment Errors" Upheld

In a decision handed down on July 23, 2013, the United States Court of Appeals for the D.C. Circuit upheld the use by CMS of outside contractors to determine whether a home health agency’s reimbursement claims had exhibited a...more

CMS Releases Proposed Calendar Year 2014 Updates to Home Health Prospective Payment System

On June 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released its proposed Calendar Year 2014 rate update to the Home Health Prospective Payment System. In addition to reducing reimbursement rates, CMS is...more

An Update on the Medicare Shared Savings Program

Accountable care organizations (“ACOs”) have been marketed as perhaps the biggest development in Medicare reimbursement since the transition from cost reimbursement to prospective payment. The Centers for Medicare & Medicaid...more

DC Circuit Issues Latest DSH Decision, Reducing Reimbursements

On June 11, 2013, the D.C. Circuit Court issued the latest ruling relating to the proper calculation of hospitals’ disproportionate share hospital (DSH) payment, leading to potentially lower Medicare reimbursements related to...more

CMS to Congress: Sequestration of Cancer Drug Reimbursement to Continue

A June 3, 2013 letter from CMS Administrator Marilyn Tavenner to Rep. Pete Sessions (R-Tex.) states that the agency does not believe it has any discretion under the Budget Control Act of 2011 to exempt Part B cancer drug...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

6th Circuit Rules in Favor of HHS on Dual-Eligible Exhausted Benefit Days Issue

On March 27, 2013, the 6th Circuit, sitting en banc, issued its decision in Metropolitan Hospital v. U.S. Department of Health and Human Services, Case Nos. 11-2465\2466. At issue in the case was whether the HHS Secretary’s...more

Hospitals: Audits And Compliance

Hospitals are under intense scrutiny. The federal government knows that one sure way to reduce healthcare costs is to get hospitals to lower their costs. Hospitals feel the pinch given the need to generate revenue but know...more

Provider Reimbursement Review Board Issues Alert 9 and Revised Rules

On March 1, 2013, the Provider Reimbursement Review Board (PRRB or the Board) issued Alert 9, which notified interested parties that the PRRB has made revisions to its Rules and updated its Model Forms. Medicare providers...more

Washington Supreme Court: Insurers May Not Reserve the Right to Seek Reimbursement of Non-covered Defense Costs

The Washington Supreme Court joined a minority of jurisdictions that hold that insurers may not unilaterally reserve the right to seek reimbursement for defense costs paid in defending non-covered claims through a reservation...more

OIG Concludes in Nationwide Review of Drug That Herceptin Has Often Been Overbilled

The HHS OIG has conducted a nationwide audit of the use and reimbursement of Herceptin (also known as trastuzumab), a Medicare-covered drug used to treat metastatic breast cancer, and has concluded in three audits released in...more

Supreme Court Opinion in Sebelius v. Auburn Regional Medical Center Rejects a Challenge by Hospitals to Medicare's SSI Fraction...

A unanimous Supreme Court has issued its opinion in Sebelius v. Auburn Regional Medical Center, No. 11-1231 (Jan. 22, 2013), rejecting a challenge by hospitals to Medicare's Supplemental Security Income ("SSI") fraction...more

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