Tag Archives: CMS

CMS Finalizes Mandatory Cardiac and Joint Bundles … But Their Future is Uncertain

When Tom Price assumes the top post at the U.S. Department of Health and Human Services (HHS) later this month (subject to Senate confirmation), the ink will barely be dry on a final rule issued by the Centers for Medicare & Medicaid Services (CMS) mandating hospital participation in two new cardiac episode-based payment models (EPMs) and an … Continue Reading

Capitol Hill Healthcare Update

A growing number of moderate and conservative Republicans in Congress are voicing concerns about the party’s strategy to repeal the Affordable Care Act (Act) in February but then wait months – and possibly even into 2018 – before developing a replacement plan. Republicans, including President-elect Trump, have said the party’s No. 1 priority is repealing … Continue Reading

Capitol Hill Healthcare Update

New Congress targets ACA repeal Republican congressional leaders overseeing the new 115th Congress will trigger a legislative process this week which will likely culminate in February with the repeal of most of the Affordable Care Act (ACA). The Senate will vote on a budget framework that will authorize separate legislation known as budget reconciliation. That … Continue Reading

Resistance Is Futile: CMS Gets Serious About Antibiotic-Resistant Bacteria

Antibiotics and similar drugs, known more broadly as antimicrobial agents, are an instrumental weapon in the healthcare armory, rendering once-lethal infections treatable, and dramatically reducing instances of sepsis and secondary infections associated with cancer chemotherapy and organ transplants. However, sub-therapeutic use of antimicrobial agents in livestock, over-prescription, bacterial evolution and myriad other factors have contributed … Continue Reading

Nursing Home Arbitration Ban: There’s a Line in the Sand – But the Tide May Still Come In

On November 7, 2016 a federal judge in Mississippi granted a request to temporarily enjoin CMS from implementing a federal rule, scheduled to take effect November 28, 2016, banning the use of mandatory pre-dispute arbitration agreements by federally-funded skilled nursing facilities (Rule). Despite noting the potential public policy arguments for the Rule, the court found that … Continue Reading

Capitol Hill Healthcare Update

Congress Adjourns, Eyes Election Then Lame Duck Congress completed work last week on a stopgap budget that keeps the government open until a post-election lame-duck voting session in December, when lawmakers are expected to move on legislation dealing with medical innovation, mental health reform and possibly efforts to stop CMS’s proposed Medicare Part B drug … Continue Reading

Summer Fraud and Abuse Roundup

Now that the kids are back in school and summer vacations are in the rearview mirror, it’s time to catch up on recent fraud and abuse developments. The federal government was busy this summer negotiating a pair of settlements under the Stark Law and anti-kickback statute, drafting changes to the Self-Referral Disclosure Protocol (SRDP), and … Continue Reading

The Proposed Medicaid DSH Rule: Hospitals, States and Associations Declare It Legally Insufficient

The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule addressing the treatment of third-party payments when calculating uncompensated care costs for the Medicaid disproportionate share hospital (DSH) formula (Proposed Rule). While CMS maintains the Proposed Rule merely clarifies longstanding policy, industry stakeholders submitting comments prior to the September 14 deadline disagree, … Continue Reading

Capitol Hill Healthcare Update

New Bill Targets Drug Prices Bipartisan legislation introduced in the Senate last week would require pharmaceutical manufacturers to alert the U.S. Department of Health and Human Services (HHS) before increasing prices more than 10 percent, continuing congressional pressure on the industry over drug pricing. The bill’s authors – including Sen. John McCain, (R-AZ) – say … Continue Reading

What Does the CMS Notice of Benefit and Payment Parameters Mean for Providers?

The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed Notice of Benefit and Payment Parameters for 2018 (Proposed Rule) a couple of months earlier than in the past – one of the administration’s many actions aimed at setting the tone going into the election and the coming year. The release of the Proposed … Continue Reading

Ambulance and Home Health Moratorium Continued and Expanded

The Centers for Medicare and Medicaid Services (CMS) recently announced an extension of its temporary moratorium on enrolling new nonemergency ambulance suppliers in New Jersey, Pennsylvania and Texas and new home health agencies in Florida, Illinois, Michigan and Texas for an additional six months. The agency also announced that the moratorium, which previously applied to specific metropolitan … Continue Reading

Year of the Bundle: CMS Proposes New Mandatory Cardiac Bundles and Expansion of CCJR

CMS is building momentum with its bundled payment programs and upping the stakes for hospitals. The Centers for Medicare & Medicaid Services (CMS) recently published a proposed rule that furthers the U.S. Department of Health and Human Services’ goal to promote cooperative, value-based care and tie at least 50 percent of Medicare payments to quality … Continue Reading

CMS Announces Final Rule Updating Fire Safety for Healthcare Facilities

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule updating fire safety requirements for healthcare facilities in an effort to increase patient safety and adapt to the needs of an aging population. The new rule adopts provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety Code (LSC), as … Continue Reading

FY 2017 IPPS Proposed Rule Results in Modest Increase for Hospitals

CMS recently issued a proposed rule updating fiscal year (FY) 2017 Medicare payment policies and rates under the Medicare inpatient prospective payment system (IPPS) and the long-term care hospital (LTCH) prospective payment system. Highlights of the proposed rule applicable to IPPS hospitals are the focus of this summary. With the proposed rule, CMS continues to emphasize its … Continue Reading

Medicaid and CHIP Managed Care Final Rule: It’s All About Consistency

The Centers for Medicare & Medicaid Services (CMS) recently issued a 1,425-page regulation (Rule) on managed care in Medicaid and the Children’s Health Insurance Program (CHIP), dubbed the first overhaul of these regulations in over a decade. CMS also issued nine “fact sheets,” indicating the Rule “supports delivery system reform efforts, strengthens program integrity by improving accountability … Continue Reading

New Medicare Part B Payment Model is Most Recent Payor Response to Increasing Drug Prices

Recent activity by the federal government along with commercial payors may be indicative of further changes to how payors, providers, and pharmaceutical manufacturers engage in prescription drug arrangements. A recently announced proposed rule by CMS would create a new Medicare Part B prescription drug payment model intended to improve quality of care and deliver better value for … Continue Reading

CMS Doubles Down on Targeting Part D Enrollee Prescription Drug Abuse, But Will Stakeholders Agree?

With the release of its 2017 draft call letter, CMS continues its push to curb opioid dependence, overdose and death among Medicare Part D enrollees. To that end, CMS proposes that Part D plan sponsors edit their benefit designs to target opioid overutilization at the point-of-sale. The letter also reminds Part D sponsors that benefit designs … Continue Reading

Providers Oppose CMS Proposal Targeting Prescription Drug Abuse by Part D Enrollees

Providers have voiced opposition to a proposal aimed at targeting Medicare Part D enrollees with “potential opioid or acetaminophen overutilization issues that indicate the need to implement appropriate controls on these drugs for the identified beneficiaries.” Under a recently proposed rule on revised discharge planning requirements, CMS solicited comments on whether providers should be required to consult … Continue Reading

Meaningful Use Stage 3 Final Rule Reduces Provider Burdens

CMS and the Office of the National Coordinator for Health Information (ONC) recently released the 752-page final rule for Meaningful Use Stages 2 (MU2) and 3 (MU3). The final rule provides a flexible timeline for providers and reduces the number of objectives and accompanying clinical quality measures required for reporting. The rule further provides that: … Continue Reading

CMS Continues Its Focus on Quality Initiatives with the FY 2016 IPPS Final Rule

On July 31, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule (Final Rule) updating fiscal year (FY) 2016 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System. While many hospitals will see increased Medicare reimbursement rates based on … Continue Reading

CMS Releases CY 2016 OPPS Proposed Rule With Updates to Two-Midnight Rule and Other IPPS Proposals

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2016 outpatient prospective payment system (OPPS)/ambulatory surgical center (ASC) payment system proposed rule that updates payment policies and rates for hospital outpatient departments and ASCs. The proposed rule also includes certain proposals relating to the hospital inpatient prospective … Continue Reading

Medicaid Managed Care Proposed Rules: The Intersection of Private Insurance and Government Programs

Approximately a quarter of all Medicaid expenditures is spent on the more than half of all beneficiaries (approximately 39 million by 2011 figures cited in the 2014 MACPAC Report) currently accessing part or all of their benefits through capitated, risk-bearing health plans or managed care organizations (MCOs). Although the government’s reliance on MCOs to manage … Continue Reading

Following FDA’s First Biosimilar License, CMS Issues Guidance on Reimbursement for Biosimilars

On March 6, 2015, FDA released a statement announcing its issuance of the first biosimilar license to Zarxio. In the same month, CMS issued a number of guidance documents addressing reimbursement for biosimilars under the Medicare Part B, Part D, and Medicaid programs. This is an initial step for CMS, and more guidance is likely … Continue Reading

New Limitations on RAC Program

In March 2014, CMS temporarily suspended the Recovery Audit Contractor (RAC) program until it secured new contracts. The contracts for the program expired in June 2014, and in August, CMS said that it would restart the program on a restricted basis under a new contract that allows recovery auditors to review a limited number of … Continue Reading
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