Tag Archives: Medicare

ILN Today Post

Healthcare: Budget deal will impact hospital acquisitions of physician practices

On Monday, President Barack Obama signed the Bipartisan Budget Act of 2015 into law. Medicare site neutral payment provisions in Section 603 of the act will restrict the ability of health systems to benefit from Medicare hospital outpatient reimbursement rates after acquiring a physician practice or ambulatory surgery center.

This landmark legislation provides the framework for the federal budget for the next two years, ensures the Department of Treasury does not default on its federal debts, replaces the across-the-board spending cuts called “sequestration” with more targeted cuts, and sets forth other policy changes. 

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ILN Today Post

D.C. Circuit Requires Greater Disclosure of Changes in Medicare Regulations

The rulemaking process often accommodates a variety of interests, including the preference of regulatory agencies to maintain some flexibility and the rights of interested parties to participate in the regulatory process. On occasion, those interests come into direct conflict. On April 1, 2014, the U.S. Court of Appeals for the District of Columbia Circuit revisited this issue and limited an agency’s ability to adopt final rules that differ dramatically from the proposed rules when the regulatory agency fails to provide adequate notice of the final rule it ultimately adopts. Allina Health Services v. Sebelius, No. 13-5011 (D.C. Cir. Apr. 1, 2014). Although this decision focused on one aspect of Medicare reimbursement, the concepts in the decision apply to the entire Medicare program and to other agency rulemaking under the Administrative Procedure Act (“APA”).

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Tacoma Physician Group Pays $14.5 Million To Settle Medicare Over-Billing Allegations

Sound Physicians, a Tacoma-based, national physician group that employs more than 700 hospitalists, paid $14.5 million to settle claims that it over-billed Medicare.  Former Sound Physicians’ employee Craig Thomas filed a whistleblower lawsuit under the qui tam provisions of the False Claims Act.  The lawsuit alleges that the company knowingly submitted inflated claims where documentation […]

For more information please visit www.omwhealthlaw.com or click on the headline above.

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ILN Today Post

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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ILN Today Post

Supreme Court Opinion in Sebelius v. Auburn Regional Medical Center Rejects a Challenge by Hospitals to Medicare’s SSI Fraction Calculation

A unanimous Supreme Court has issued its opinion in Sebelius v. Auburn Regional Medical Center, No. 11-1231 (Jan. 22, 2013), rejecting a challenge by hospitals to Medicare’s Supplemental Security Income (“SSI”) fraction calculation, which affects the reimbursement amount health care providers receive for inpatient services rendered to Medicare beneficiaries and any upward payment adjustment for serving a disproportionate number of low-income patients. In doing so, the Court reversed the judgment of the U.S. Court of Appeals for the District of Columbia Circuit (“D.C. Circuit”) allowing an administrative appeal made 10 years after the initial reimbursement determination.

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ILN Today Post

Supreme Court Opinion in Sebelius v. Auburn Regional Medical Center Rejects a Challenge by Hospitals to Medicare’s SSI Fraction Calculation

A unanimous Supreme Court has issued its opinion in Sebelius v. Auburn Regional Medical Center, No. 11-1231 (Jan. 22, 2013), rejecting a challenge by hospitals to Medicare’s Supplemental Security Income (“SSI”) fraction calculation, which affects the reimbursement amount health care providers receive for inpatient services rendered to Medicare beneficiaries and any upward payment adjustment for serving a disproportionate number of low-income patients. In doing so, the Court reversed the judgment of the U.S. Court of Appeals for the District of Columbia Circuit (“D.C. Circuit”) allowing an administrative appeal made 10 years after the initial reimbursement determination.
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Stage 2 Meaningful Use Final Rules Announced

After much delay and anticipation, the Stage 2 Meaningful Use Final Rules were announced late last week.  Though the primary focus of the new rules were to update (and increase) the meaningful use objectives and measures for the Medicare and Medicaid EHR Incentive Program, significant additional components regarding the EHR Incentive Program were also included.  To read the 672 pages of the Final Rule click here.  CMS has also posted a fact sheetwhich provides a good high level summary of some of the main topics of the Final Rule.  In addition to the Meaningful Use final rules, the Office of the National Coordinator has released its new standards governing certified EHR technology and a fact sheet.  The National eHealth Collaborative hosted a helpful webinar with an overview of these new rules, which can be accessed here.  

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HHS Announces First Insurance Premium Rate Review Determinations: Implications for Insurance Carriers and Future Rate Reviews

by Jesse M. Caplan and Serra J. Schlanger

On November 21, 2011, the Center for Consumer Information & Insurance Oversight, in the Centers for Medicare & Medicaid Services (“CMS”), announced its determination that a health insurance premium rate increase of 11.58 percent in the small group market in Pennsylvania represented an “unreasonable” rate increase, while an 11.10 percent increase in the individual market in Montana did not. These long-awaited determinations represent the first application of CMS’s rate review regulations under federal health reform.

This Implementing Health and Insurance Reform alert discusses these first federal rate review determinations, and their implications for insurance carriers and future insurance premium rate reviews. It also provides a link to Epstein Becker Green’s interactive National Health Insurance Rate Review Scorecard, which offers insurance carriers, lawyers, and other stakeholders an up-to-date resource on federal and state health insurance rate review programs, standards, and initiatives.

Read the full alert here

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Medicare Providers and Suppliers Continue in the Spotlight: Medicare Providers and Suppliers Continue in the Spotlight

Expansion of the DMEPOS Competitive Bidding Program; Legislative Inquiry Related to Fraud and Abuse Enforcement Actions; and Automated Pre-Enrollment Provider Screening

by George B. Breen, Amy F. Lerman, Emily E. Bajcsi, Deepa B. Selvam

In order to be prepared for upcoming changes and to respond to new initiatives, providers and suppliers participating in Medicare must be aware of recent Congressional activity that would hold the federal government accountable for its intended enforcement efforts designed to curb health care fraud, waste, and abuse, as well as an effort by the Centers for Medicare & Medicaid Services (“CMS”) to implement automated pre-enrollment provider and supplier screening in January 2012. One example of the pressures that providers and suppliers face in this enhanced regulatory and enforcement climate is the upcoming expansion of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (“DMEPOS”) Competitive Bidding Program, which is targeted to launch in July 2013 and for which the Round 2 bidding timeline was announced on November 30, 2011.

Read the full alert here

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ILN Today Post

HEALTH REFORM: Medicare Providers and Suppliers Continue in the Spotlight

In order to be prepared for upcoming changes and to respond to new initiatives, providers and suppliers participating in Medicare must be aware of recent Congressional activity that would hold the federal government accountable for its intended enforcement efforts designed to curb health care fraud, waste, and abuse, as well as an effort by the Centers for Medicare & Medicaid Services (“CMS”) to implement automated pre-enrollment provider and supplier screening in January 2012. One example of the pressures that providers and suppliers face in this enhanced regulatory and enforcement climate is the upcoming expansion of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (“DMEPOS”) Competitive Bidding Program, which is targeted to launch in July 2013 and for which the Round 2 bidding timeline was announced on November 30, 2011.

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