Tag Archives: Medicare

Capitol Hill Healthcare Update

Editor’s Note – The next Capitol Hill Healthcare Update will be published after Labor Day when Congress reconvenes following its August recess. Republicans Contemplate Next Steps Amid ACA Flameout Congressional Republicans and President Donald Trump face a series of key questions about how or whether to fortify the Affordable Care Act – particularly in the … Continue Reading

Capitol Hill Healthcare Update

Senate Readies for Key Procedural Vote on Healthcare Bill – Maybe Senate Republicans face a key procedural vote this week that would allow for debate of their healthcare legislation, but significant uncertainty remains about whether GOP senators can meet that procedural hurdle, what the underlying healthcare bill would be and how an impending White House … Continue Reading

Capitol Hill Healthcare Update

Delayed Senate Health Vote Boon to GOP or Just Prolonging the Inevitable? Senate Majority Leader Mitch McConnell’s announcement that he would delay a key procedural vote scheduled for this week on the Republicans’ healthcare overhaul gave the GOP yet more time to find a legislative solution that can pass the Senate. But given McConnell’s inability … Continue Reading

Ch-Ch-Ch-Ch-Changes: Reporting Requirements for Updating Your CMS Provider Enrollment

With the possibility of significant penalties for improperly reported transactions, it is important to understand how certain changes necessitate specific reporting. Is your organization considering a stock transfer, a merger, a change in control, building a new practice location or updating its board of directors? If these kinds of changes are afoot, it is critical … Continue Reading

The DOJ Enters Another FCA Lawsuit Against UnitedHealth

The U.S. Department of Justice (DOJ) recently filed its complaint in intervention in another whistleblower lawsuit brought under the False Claims Act against the nation’s largest owner and operator of Medicare Advantage (MA) organizations, UnitedHealth Group, Inc. (United). The DOJ’s 39-page complaint alleges that United had fraudulently obtained inflated risk adjustment payments by over reporting diagnosis … Continue Reading

Capitol Hill Healthcare Update

CBO Score of House Health Bill Set for This Week Congress’s official budget scorekeepers this week will release analysis of the House-approved bill repealing most of the Affordable Care Act (ACA), and that data will inform Senate Republicans on a path for passing their version of the legislation. The Congressional Budget Office (CBO) and the … Continue Reading

IPPS Proposed Rule Increases Hospital Payment; Solicits Ideas for Achieving Transparency, Relieving Administrative Burden

The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed rule updating fiscal year (FY) 2018 payment policies and rates under the Medicare inpatient prospective payment system (IPPS). As highlighted below, the proposed rule aims to reduce regulatory burdens for providers and to promote transparency and flexibility in the delivery of care. Comments … Continue Reading

Bundled Payments Out in the Cold? Another Delay for Mandatory Bundled Payment Models

This most recent delay raises questions concerning how the Trump administration intends to implement value-based payment in the Medicare program. The Centers for Medicare and Medicaid Services (CMS) has delayed again the implementation date of its final rule mandating hospital participation in two new cardiac episode-based payment models (EPMs) and an expansion of the Comprehensive … Continue Reading

Capitol Hill Healthcare Update

At HHS, Price will lead Trump’s efforts on ACA repeal Three weeks into President Trump’s administration, the Senate on Friday narrowly approved Tom Price as Secretary of the U.S. Department of Health and Human Services (HHS), elevating the former orthopedic surgeon as Trump’s point person on repealing and replacing the Affordable Care Act (ACA). Price … Continue Reading

Capitol Hill Healthcare Update

GOP leaders delay ACA action amid “repeal,” “repair” debate House Speaker Paul Ryan last week set a deadline of the end of March for repealing most of the Affordable Care Act (ACA), as other Republican leaders and conservative rank-and-file lawmakers advocated competing policy alternatives for what would follow the health law. Congressional Republicans had hoped … Continue Reading

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

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

Making Sense of MACRA

Bracing for the Medicare Part B Overhaul:  Pick a Path, Pick a Pace The countdown has begun for the momentous Part B payment reforms created by the Medicare Access and Chip Reauthorization Act of 2015 (MACRA). On October 14, 2016, CMS released a final rule explaining, in nearly 2,400 pages, how its new Quality Payment Program, established under MACRA, … Continue Reading

Dialing for Dollars Yields Conviction for Home Health Telemarketer

Sundae Williams, the owner of Serenity Marketing Inc., made unsolicited phone calls to recruit patients, including Medicare beneficiaries, for contracted home health agencies. Williams and Serenity then referred those patients to the home health agencies in exchange for payments on a per-patient basis. Williams was convicted on one count of conspiracy and six counts of … Continue Reading

Medicare Advantage Plan Arbitration Clauses Preempted by Medicare Appeals Process

The Arizona Supreme Court, in an interesting case involving a Medicare-related coverage dispute between a Medicare Advantage plan administrator, United Behavioral Health (UBH), and two inpatient psychiatric care providers, held that the Medicare administrative appeals process preempts the arbitration language contained in the UBH provider agreements. The court also remanded the case back to the … Continue Reading

Congress is Back in Session – So What Now for Healthcare?

With Congress reconvening after a seven-week summer recess, we wanted to provide you with a quick topline of key healthcare issues lawmakers are expected to consider this week. Zika Funding The Senate voted September 6 – and as expected – failed to overcome a Democratic filibuster of new funding to combat the Zika virus. Congress earlier this … 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

A Tale of Two Escobars: Federal Courts Begin Grappling with Opposing Views of “Materiality”

On June 16, 2016, the U.S. Supreme Court issued a highly anticipated opinion in Universal Health Services, Inc. v. U.S. ex rel. Escobar, which for the first time expressly recognized implied certification as a viable theory under the federal False Claims Act (FCA). Implied certification is a theory that has been widely criticized by government contractors … 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

No Longer Implied: Supreme Court Expressly Recognizes Implied Certification as a Theory of Liability Under the False Claims Act

Court Rejects the First Circuit’s “Expansive View” of the Theory by Articulating “Rigorous” Standards of Materiality Yesterday, the U.S. Supreme Court issued a long-anticipated decision on the viability of the “implied certification” theory of liability under the False Claims Act (FCA). In Universal Health Services, Inc. v. United States ex rel. Escobar, a unanimous Court … 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
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