News & Analysis as of

Medical Reimbursement

The 340B Drug Pricing Program: New CMS Final Rule Draws a Motion for Preliminary Injunction from Hospital Groups

On November 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the final rule, “Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting...more

K&L Gates Triage: 340B Update: CMS Finalizes 340B Program Reimbursement Cut on Part B Drugs

by K&L Gates LLP on

In this episode, Richard Church and Ryan Severson discuss the recent decision by the Centers for Medicare and Medicaid Services (CMS) to substantially decrease reimbursement under the Outpatient Prospective Payment System...more

Newly-Announced 340B Payment Rule Presents Financial & Operational Challenges to All Covered Entities

by Polsinelli on

In its 2018 Outpatient Prospective Payment System final rule (Final Rule) issued Nov. 1, Centers for Medicare and Medicaid Services (CMS) implemented a significant Medicare Part B payment reduction for separately payable,...more

Managing the Interplay Between the ADA, FMLA and WC

by Foley & Lardner LLP on

The following description may seem quite familiar to those who deal with employee issues on a daily basis. Your employee, who has a physically demanding job on the factory floor, has been out on leave for an injury that he...more

Expanding Association Health Plans—Which Agencies Need to do What

On October 13th, President Trump signed an Executive Order directing various federal agencies to consider how to achieve three administration health reform objectives: (1) expand access to Association Health Plans (AHPs); (2)...more

Recent Merger Reflects Enhanced Need for Revenue Cycle Management Platforms

Two of the nation’s most noteworthy companies in the Revenue Cycle Management (“RCM”) technology space, Navicure Inc., and ZirMed Inc., announced a merger on September 14, 2017....more

“A Strong Pull on the Threads Holding Obamacare Together:” President Trump’s October 12, 2017 Affordable Care Act Executive Order

by LeClairRyan on

President Trump’s Executive Order titled “Promoting Healthcare Choice and Competition Across the United States” seeks to reform certain aspects of the Affordable Care Act (“ACA” or “Obamacare”) by Executive Agency action...more

The Way Forward for Telemedicine

by McDermott Will & Emery on

A lot of us have argued that one of the floodgates for telemedicine has been reimbursement. If states and the Federal government more liberally reimbursed or required reimbursement for telemedicine service, we argue then a...more

Court Finds Provider Failed to Exhaust Administrative Remedies in Suit Against Government Contractor for Withheld Reimbursement

by King & Spalding on

On August 28, 2017, the United States District Court for the Eastern District of Michigan held that a provider must fully exhaust administrative remedies before it can seek a remedy in Federal court against a Medicare...more

CMS Limits Required Participation in Comprehensive Care for Joint Replacement Model; Cancels Episode Payment Models

On August 15, 2017, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would significantly roll back two of CMS’s mandatory alternative payment models. The Proposed Rule would make continued...more

San Antonio Businessman Sentenced To Four Years in Prison for Defrauding Personal Injury Clients, the Bankruptcy court, and the...

by Moskowitz LLP on

From 2009 through 2014, Elpidio Gongora (aka “Pete Gongora”), operated a number of personal injury law offices in Texas, Arkansas and New Mexico. The lawyers in these firms apparently obtained settlements on behalf of their...more

Beware of TennCare Reimbursement and Prescribing Issues - TennCare Completes Implementation of the ACA's Medicaid Registration...

Due to recent TennCare changes, health care providers not registered with TennCare should consider registering to avoid issues in prescribing for TennCare patients and to preserve TennCare revenue. ...more

Medicare Claims Appeals: D.C. Circuit Reverses and Remands in Case Seeking Relief From Processing Delays

by Foley & Lardner LLP on

On August 11, 2017, the D.C. Circuit reversed the district court and held that the district court abused its discretion by ordering the Secretary of HHS to clear the backlog of administrative appeals of denied Medicare...more

K&L Gates Triage: 340B Regulatory Update: CMS Proposal and Draft Executive Order Could Have Big Impact on 340B Program

by K&L Gates LLP on

cmsThis episode outlines the basics of the 340B Drug Pricing Program and discusses potential changes affecting the program, including CMS’s recent proposal to cut reimbursement for Part B drugs purchased under the 340B...more

Value Based Reimbursement: CMS Dials Back; Large Employers Forge Ahead

by Pierce Atwood LLP on

Last week, CMS announced in proposed rulemaking its proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model. It also announced plans to revise certain aspects of the...more

Medicare Secondary Payer Act Class Actions

There have been a substantial number of putative class actions filed recently against insurers involving the Medicare Secondary Payer Act (MSPA). These cases are typically filed by assignees of Medicare advantage...more

CMMI Focuses on Behavioral Health

by Pierce Atwood LLP on

CMS recently announced that the Center for Medicare and Medicaid Innovation (CMMI) is interested in lowering the cost of care for Medicare and Medicaid beneficiaries with behavioral health conditions while improving the...more

Is Your Surgery Center Ready for California’s Surprise Medical Billing Law?

by Nossaman LLP on

A new California law (AB 72) limits the amount that out-of-network surgeons and other health care professionals may bill patients for covered non-emergency services provided at a contracted facility, such as an ambulatory...more

Patient Safety Issues Highlighted in DOJ Settlement and Health Care Industry Cybersecurity Task Force Report

by Pierce Atwood LLP on

As we know, the move away from fee for service reimbursement models is not only intended to reduce costs by no longer paying providers based on the volume of services performed, but is also intended to improve the overall...more

Nurse Anesthetists Sue Novitas Solutions and CMS Over Medicare Reimbursement Policy on Chronic Pain Management

by King & Spalding on

On April 11, 2017, the American Association of Nurse Anesthetists (AANA), an organization representing more than 50,000 Certified Registered Nurse Anesthetists (CRNAs), filed a complaint for declaratory and injunctive relief...more

Merger and Acquisition Activity in the Rehabilitation, Home Health and Hospice Sectors Increased in 2016, But Will this Trend...

Since 2014, there has been a steady increase in mergers and acquisitions in the Rehabilitation sector, with a total of 40 deals announced in 2016. This is almost double the number of deals in 2014 (a total of 21), and...more

Obamacare Reform Watch: Reimbursement Strategies in an Environment of Growing Out-of-Pocket Costs and an Expanding Self-Pay...

by Hinshaw & Culbertson LLP on

The increase in patient financial responsibility for health care costs in the past ten years has outpaced consumer growth in wages. This escalation of out-of-pocket costs represents a major revenue cycle challenge for health...more

Managing the Transition to Transformation: Expanding the Health Care Paradigm

by McDermott Will & Emery on

McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and care delivery...more

Will Florida's Crazy PIP Litigation Soon Be a Thing of the Past?

Following an automobile accident, injured parties need immediate funds to pay for medical expenses. To ensure that injured persons have the ability to obtain necessary healthcare, Florida law requires auto insurers to...more

Medicare Secondary Payer – A Lot Less Boring Now

by Reed Smith on

We’ve previously written several posts (not recently) on Medicare secondary payer (“MSP”) issues – which we characterized as “boring.” The recent MSP decision, Humana Insurance Co. v. Paris Blank LLP, 2016 WL 2745297, 187 F....more

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