Tag Archives: Medicaid

Breaking News: 60-Day Overpayment Rule Finalized

The Centers for Medicare and Medicaid Services (CMS) released its final rule implementing Section 6402(a) of the Affordable Care Act that requires Medicare providers and suppliers to report and return overpayments within 60 days after the date on which the overpayment was identified in most instances. Failure to report and return overpayments in accordance with … Continue Reading

Drug Manufacturer Discount Cards: Accept With Caution

Pharmaceutical manufacturer discount card usage by government program beneficiaries has been an active area for government action in recent years.  In a September 2014 Special Advisory Bulletin, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) stated, “[t]hese coupons constitute remuneration offered to consumers to induce the purchase of specific items.” … Continue Reading

Implied Certification and the FCA: Legally False or a False Legality? The Supreme Court Is Set to Decide

The United States Supreme Court recently granted certiorari in the case of Universal Health Services, Inc. v. U.S. ex rel. Escobar, No. 15-7, which places implied certification under the False Claims Act (FCA) squarely in the judicial crosshairs. Implied certification is a frustrating theory of liability for providers and contractors that receive government reimbursement, due to … Continue Reading

Kane and the “60-Day Rule”: The Unforgiving World of Medicare and Medicaid Overpayments

The Southern District of New York has spoken on one of the first issues to confront those seeking compliance with the new “60-day rule” under the Affordable Care Act (ACA), and it does not bode well for defendant hospitals and providers. On August 3, 2015, the district court in Kane v. Healthfirst, Inc., issued its … Continue Reading

Texas Medicaid Managed Care: Expedited Credentialing Requirement Added Along With Additional Oversight and Accountability

The Texas Legislature in Senate Bill 760 removed barriers to Medicaid recipients receiving healthcare services and required improved access for services through managed care plans. Expedited Provider Credentialing The legislation requires that Medicaid managed care organizations (MCO) establish and implement an expedited credentialing process that would allow certain applicant providers to provide services to recipients … Continue Reading

HHS OIG Creates New Taskforce to Pursue Civil Monetary Penalties and Exclusions

If you have any questions concerning this article, please contact: B. Scott McBride at smcbride@bakerlaw.com or 713.646.1390; Greg Saikin at gsaikin@bakerlaw.com or 713.646.1399 from our Healthcare Investigation and Enforcement team; John J. Carney at jcarney@bakerlaw.com or 212.589.4255; George A. Stamboulidis at gstamboulidis@bakerlaw.com or 212.589.4211 from our White Collar Defense and Corporate Investigations team; or Hilary … 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

Five Things to Know About the Medicare SGR Fix

H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), was signed into law by President Obama on April 16, 2015. A broad bipartisan compromise measure, MACRA repeals the much-maligned sustainable growth rate (SGR) formula used to determine physician payment rates and replaces it with a new incentive payment system; extends funding for the Children’s … Continue Reading

Children’s Hospitals Obtain Temporary Injunction Against CMS

Court Enjoins CMS’s Interpretation of Medicaid DSH Reimbursement Formula Challenging actions by the Centers for Medicare & Medicaid Services (CMS) under the Administrative Procedures Act (APA), Texas Children’s Hospital and Seattle Children’s Hospital obtained a preliminary injunction that enjoins CMS’s actions concerning informal instructions it provided to its auditors for calculating disproportionate share hospital (DSH) … Continue Reading

Who Decides When Medicaid Payment Rates Are Not Enough?

In 2005, the Florida Pediatric Society, the Florida Association of Pediatric Dentists, and a number of parents and guardians on behalf of their individual children in the Medicaid program brought suit against the state of Florida alleging violations of the following: 42 U.S.C. § 1396a(a)(8) and (a)(10) – requiring that children receive medical and dental … Continue Reading

Medicaid ACOs: States’ Answer to Escalating Costs?

States increasingly are experimenting with the use of Accountable Care Organizations (ACOs) in their Medicaid programs as a possible avenue to curb the escalating costs of providing care to expanding Medicaid populations. Although there has yet to be a universally accepted definition for ACOs, they generally are recognized to be provider-run collaborations in which the … Continue Reading

Government Sues Hospital for Birthing Mama’s Babies

The Clinica de la Mama case could well serve as an instruction manual of what not to do to stay out of the government’s crosshairs. In this case, several hospitals entered into contracts for Clinica de la Mama to provide “services” including translation, translation management, consulting, eligibility determination, marketing, birth certificate, educational, community outreach and … Continue Reading

Academic Medical Centers: Clinical Care, Research and Teaching (or Maybe Not?)─Graduate Medical Education and the Future

In the world of healthcare policy and law, we usually discuss issues impacting providers, but don’t often report about the training and infrastructure behind what allows our healthcare system to treat patients in our facilities. Many warnings have come and gone about how we are not training enough physicians for primary care, and the ACA … Continue Reading

United States Supreme Court Strikes Down Illinois Regulatory Framework Requiring Personal Assistants for Medicaid Recipients to Pay Union Dues or Fees

Editor’s Note:  This post originally appeared on BakerHostetler’s Employment Law Spotlight blog. In its much anticipated decision in Harris v. Quinn, 573 U.S. __ (2014), the Supreme Court of the United States in a five to four ruling struck down an Illinois regulatory framework that required personal assistants (PAs) for Medicaid recipients to pay agency … Continue Reading

Annual Legislative Seminar Celebrates 25 Years

This year’s Annual Legislative Seminar, held on May 7, marked the event’s 25th anniversary and featured a distinguished lineup of speakers, including 19 members of the Senate and the House who addressed issues, such as federal tax reform, the federal budget, implementation of the Affordable Care Act and proposed legislation addressing patent reform. The event, … Continue Reading

Stark Law Update: All Children’s Settles False Claims Act Allegations

All Children’s Health System (ACHS) will pay the federal government and state of Florida $7 million to settle allegations that it violated the federal and Florida False Claims Act statutes by submitting claims to Medicaid that were illegal under the Stark Law. The whistleblower in the case was the Director of Operations of Pediatric Physician … Continue Reading

Five Health Policy Issues to Watch in 2014

As we head into the mid-term election cycle, the ongoing implementation of the Patient Protection and Affordable Care Act (ACA) continues to consume the nation’s healthcare industry and political leaders in 2014. On the horizon are several issues likely to dominate congressional time, despite the health policy fatigue felt by most legislators. Below is a … Continue Reading

There’s a Code for That: Counting Down to ICD-10 and a Poem to Help You Remember!

Editor’s Note:  We originally published this article to our Health Law Update Blog prior to Congress extending the ICD-10 compliance deadline.  Therefore, we have revised our language to indicate that changes to coding are coming in the fall 2015, not 2014. ————————————————————– ~We wrote down this poem, To help you recall, That changes are coming … Continue Reading

Ohio Medicaid Expansion Underway

Last fall, Ohio became the 25th state to file a state plan amendment to extend Medicaid benefits to approximately 275,000 Ohioans who previously were not eligible for the program. In doing so, Ohio also agreed to accept an additional $2.5 billion in federal Medicaid payments. The Kasich administration believes the move will improve Medicaid and … Continue Reading

There’s a Code for That: Counting Down to ICD-10 and a Poem to Help You Remember!

————————————————————– ~We wrote down this poem, To help you recall, That changes are coming To coding this fall.~ ————————————————————– On October 1, 2014, all HIPAA-covered persons and entities must be compliant with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM and ICD-10-PCS, respectively).  Despite numerous extensions of this compliance date (which was … Continue Reading

Proposed $6.8M Fine Related to Puerto Rico Breach Incident

Triple-S Salud, Inc. (Triple-S), a Puerto Rico Health Insurance Administration (PRHIA) contractor, filed a Form 8-K indicating that the PRHIA intended to impose a civil monetary penalty (CMP) of $6,768,000 and other administrative sanctions stemming from a breach incident affecting 13,336 dual eligible Medicare beneficiaries.  The breach incident occurred in September 2013 when Triple-S mailed to … Continue Reading

Marketing to Medicaid Beneficiaries: Texas Proposed Rule Highlights Pitfalls for Providers

Earlier this month, the Texas Health and Human Services Commission (Commission) released a proposed rule, 1 TAC § 354.1452 that prohibits certain marketing activity by Medicaid and CHIP providers. The proposed rule has been created to enforce the restrictions on provider marketing activities enacted in SB 8, 83rd Legislature, Regular Session, 2013. Subject to the … Continue Reading

Medicaid DSH: Little-Noticed CMS Rule Interpretation Creates Serious Financial Shortfalls for Impacted Hospitals

In what may have been a largely unnoticed rule interpretation affecting hospitals that treat a high percentage of children in the Medicaid program, CMS, in January 2010, issued a response to a Frequently Asked Question (FAQ) regarding the December 19, 2008, Medicaid disproportionate share hospital (DSH) audit rule (DSH Final Rule). Specifically, the CMS FAQ … Continue Reading
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