Tag Archives: Centers for Medicare & Medicaid

Healthcare Alert: CMS issues guidance and ACO physician exclusivity

The Centers for Medicare & Medicaid Services (CMS) recently updated its Medicare Shared Savings Program (MSSP) FAQs by adding 13 questions and answers that provide important guidance on the ability of physicians to participate in multiple accountable care organizations (ACOs).

Contrary to the common misconception that only primary care physicians are required to be exclusive to a single ACO, and that specialists are free to participate in multiple ACOs, the update clarifies that if a group practice (or other entity) bills Medicare for services under any of the billing codes that fall within the definition of “primary care services,” the taxpayer identification number (TIN) of the group is not allowed to appear on the participant lists for multiple ACOs. It is important to keep in mind that the ACO regulations broadly define “primary care services” as all services that fall within certain billing codes, including CPT codes for evaluation and management (E&M) services in various office, outpatient, nursing facility and home settings, regardless of the specialty of the physician. Primary care physicians and specialists alike will therefore generally be precluded from participating in multiple ACOs if their services are billed under any of these E&M codes, or if the services of other physicians, nurse practitioners, physician assistants or clinical nurse specialists are billed by their practice entity under those codes.

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CMS Innovation Center Announces Four Models in Bundled Payments for Care Improvement Initiative

by Lesley R. Yeung, Shawn M. Gilman, and Serra J. Schlanger

On August 23, 2011, the Centers for Medicare & Medicaid Services (“CMS”) Innovation Center announced a new initiative to encourage health care providers to better coordinate patient care. The Bundled Payments for Care Improvement Initiative (“Bundled Payments Initiative”) seeks to align the financial incentives among hospitals, physicians, and non-physician practitioners through the use of a single negotiated payment for all services provided during an episode of care. The use of a bundled payment is expected to encourage hospitals, doctors, and other specialists to coordinate in treating a patient’s specific condition during a single hospital stay and recovery.

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Rick Hindmand was featured in "CMS Regulations Expand Enrollment Screening Procedures and Authority to Suspend Payment," published by RBMA

CMS Regulations Expand Enrollment Screening Procedures and Authority to Suspend Payment
By: Rick Hindmand

The Centers for Medicare & Medicaid Services (CMS) recently announced a final rule (the “Rule”) adopting three levels (limited, moderate and high) of screening standards for Medicare, Medicaid and Children’s Health Insurance Program (CHIP) providers and suppliers based on the level of risk for fraud. The Rule also establishes procedures for the imposition of moratoria on the enrollment of categories of providers, and establishes procedures for the suspension of Medicare and Medicaid payments, in whole or in part, in cases of “credible allegations of fraud.”

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