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OIG February 2018 Work Plan Update

The OIG added three items to its Work Plan with the February 2018 update, as listed in the chart below. Two of the items concern annual reports, one addressing the performance of Medicaid Fraud Control Units and the other...more

Post-Acute Care Providers Ponder Role in BPCI Advanced

As CMS's approach to Alternative Payment Models continues to evolve, most recently with the release of BPCI Advanced, post-acute care providers may be left scratching their heads as they try to determine where they fit. An...more

Vitas Hospice and Chemed Corporation Settle Largest-Ever FCA Claim Against a Hospice

Vitas Hospice, the largest for-profit hospice chain in the United States, and its owner, Chemed Corporation, agreed to pay $75 million to settle allegations that Vitas Hospice submitted false claims for hospice services...more

Pharmacy Chain's Benefit Program Gets OIG Approval in Advisory Opinion 17-05

The OIG approved a retail pharmacy chain's proposal to expand its benefit program, which allows participating federal health care program beneficiaries to receive discounts and other benefits when purchasing certain products...more

CMS Extends Comment Period for New SNF PPS Methodology Proposal

On May 4, for the first time in nearly 15 years, CMS issued an Advanced Notice of Proposed Rulemaking (ANPRM) proposing a total overhaul of the current reimbursement methodology for skilled nursing facilities (SNFs). The...more

CMS Proposes to Eliminate Therapy-Driven SNF Reimbursement

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

Deemed Providers Beware: IPPS Rule Proposes Publicizing Accreditation Survey Results

The veil of secrecy may soon be lifted from the reports of accreditation organizations like The Joint Commission if a proposal in the April 28, 2017 Inpatient Prospective Payment System (IPPS) Proposed Rule is finalized. As...more

OIG Approves Another Medigap/Preferred Hospital Network Arrangement in Advisory Opinion 16-11

On November 3, 2016, the OIG issued another favorable Advisory Opinion, No. 16–11, regarding an agreement between a Medigap insurer and preferred hospital network. The OIG has issued several opinions regarding similar...more

Home Health Agency PPS Update for 2017: Quality, Quality, Quality

On November 3rd, CMS published the Final Prospective Payment System (PPS) Rule for Home Health Agencies (HHAs) for CY 2017 at 81 FR 76702 (Nov. 3, 2016). The rule implements annual changes to the PPS rate for HHAs and...more

CMS Warns Against Social Media Postings Involving Nursing Facility Residents

In an August 5, 2016, Survey and Certification memorandum to state Survey Agency Directors, the Centers for Medicare and Medicaid Services (CMS) directs surveyors of nursing facilities on matters relating to the use of social...more

SNF and IRF Proposed Changes for FY 2017

On August 5th, CMS published final rules updating the Medicare payment rates for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) for FY 2017. The rules, both of which go into effect on October...more

Bankruptcy Courts Lack Subject Matter Jurisdiction Over Medicare Issues, Eleventh Circuit Rules

In a detailed opinion that likely constitutes the last word on the matter, the Eleventh Circuit recently held in Fla. Agency for Health Care Administration v. Bayou Shores SNF, LLC that bankruptcy courts lack jurisdiction...more

Home Health PPS CY 2017 Proposed Rule: Payments Rebased, Quality Measures Updated

Downward adjustments to home health episode payments arising from rebasing of the national payment rates, case mix adjustments, and an increase to the fixed dollar loss ratio for calculating outliers will result in an overall...more

CMS Limits MAC and QIC Scope of Review

Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) should not expand redeterminations and reconsiderations of claims denied on the basis of complex pre–or post–pay payments or automated...more

OIG Updates Permissive Exclusion Criteria – Suggests Compliance Programs Are Expected

On April 18th, the Office of Inspector General (OIG) issued updated guidance describing the factors it will consider in determining whether to exercise its permissive authority to exclude individuals and entities from federal...more

OIG Approves Another Medigap/Preferred Hospital Network in Advisory Opinion 16-04

On April 18th, the OIG issued a new favorable Advisory Opinion, No. 16–04, regarding an agreement between a Medigap insurer and preferred hospital network. The opinion tracked other, similar opinions in favorably addressing...more

OIG Approves Another Patient Assistance Program in Advisory Opinion 15-16

On December 28, 2015, the Office of Inspector General (OIG) approved another patient assistance program in Advisory Opinion 15-16. The OIG analyzed contributions to a private charitable organization under the anti-kickback...more

Outliers: CMS Explains its Reasoning for FY2004 Fixed Loss Threshold Calculation

In accordance with the order issued by the D.C. Circuit in District Hospital Partners, LP v. Burwell and related cases, on January 22, CMS issued an explanation of the methodology it used to calculate the fixed-loss threshold...more

CMS Issues CY 2016 HHA PPS, Value-Based Purchasing and Quality Reporting Final Rule

On November 5th, CMS published the Final PPS Rule for Home Health Agencies (HHAs) for CY 2016. The rule implements annual changes to the PPS rates for HHAs and represents the third year in a four-year rebasing of the rates....more

Value-Based Payments Transition to Post-Acute Care: The FY 2016 Skilled Nursing PPS Rule

CMS published the final FY2016 Skilled Nursing Facility Prospective Payment System rule on August 4, 2015. In addition to updating the overall payment rate, the new rule implements key features of the Protecting Access to...more

District Court Issues First Decision Interpreting ACA's 60-day Rule

The first case to interpret when the clock begins to run on the “60-Day Rule” did not go well for health care providers. On August 3rd, the Southern District of New York rejected defendants HealthFirst, Inc.’s and Continuum...more

CMS Proposes Limited Exception to Two-Midnight Rule and QIO Review of Short Stays

In the 2016 inpatient prospective payment system (IPPS) proposed rule, CMS promised to provide further guidance on the controversial "two midnight" rule in the forthcoming outpatient prospective payment system (OPPS) rule....more

Stark Regulations: Technical Revisions

The proposed Physician Fee Schedule for CY 2016 includes multiple technical revisions to the regulations implementing the Stark law. These revisions appear to be designed to provide greater clarity and flexibility with...more

CMS Releases Proposed IPPS Rule

On April 17, 2015, CMS released a copy of its proposed changes and updates to the Medicare inpatient prospective payment system (IPPS) for fiscal year 2016. The official version appears in the April 30th Federal Register, and...more

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