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Showing 57 posts in Centers for Medicare & Medicaid Services (“CMS”).

The Pioneer Program Report Card

August 6, 2013
Posted In Accountable Care Organizations (“ACO”), Centers for Medicare & Medicaid Services (“CMS”), Health Care Law, Medicaid, Medicare, Medicare Shared Saving Program (MSSP), Patient Protection and Affordable Care Act (“ACA”)

In 2012, thirty-two organizations were selected to participate as “Pioneers” in a pilot Accountable Care Organization (“ACO”) program created through the Affordable Care Act (“ACA”).  The program’s goals were to revolutionize the health system and reduce medical costs by basing physician and hospital pay on quality rather than quantity. More >

Proposed Payment Changes for Medicare Home Health Agencies, cont.

August 1, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Department of Medicaid Services’ (“DMS”), Home Health Prospective Payment System, Quality reporting

Earlier this week, I discussed CMS’ proposal to rebase the payment rates for home health services. Here I will discuss CMS’ other proposed changes to home health payment. More >

Proposed Payment Changes for Medicare Home Health Agencies

July 30, 2013
Posted In Affordable Care Act, Centers for Medicare & Medicaid Services (“CMS”), Home Health Prospective Payment System, Low-utilization payment adjustment ("LUPA"), Medicare, Nonroutine medical supplies conversion factor (“NRS”)

The Centers for Medicare and Medicaid (“CMS”) recently released a proposed rule involving 2014 payment changes for the Home Health Prospective Payment System. The rule projects that the changes could reduce Medicare payments to home health agencies by 1.5 percent. CMS estimates that 3.5 million beneficiaries currently receive home health services, costing Medicare approximately $18.2 billion in 2012, so a 1.5 percent reduction would be significant ($290 million, to be exact). More >

CMS Ruling on Part B Rebilling

June 11, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Health Care Law, Medicare Administrative Coordinators, Medicare Benefit Policy Manual, Part A, Part B, Recovery Audit Contractors (“RAC”)

Increasingly, Administrative Law Judges (“ALJs”) and the Medicare Appeals Council were upholding Part A denials on RAC audit appeals based on determinations that inpatient admissions were not reasonable and necessary, and then ordering payment under Part B as if services were rendered at an outpatient or “observation level” of care. The problem with this practice is that Medicare Benefit Policy Manual (“MBPM”) allows hospitals to bill a Part B inpatient claim for only a limited set of medical and other health services. Additionally, the providing for payment of all reasonable and necessary Part B services under these circumstances are contrary to CMS policy that the services be billed within the usual timely filing restrictions. The Centers for Medicare & Medicaid Services (“CMS”), concerned about this practice, recently released both a Ruling and a Proposed Rule to seemingly help the hospital community. How much relief it will actually provide is yet to be seen. More >

Final Rule for Physician Payments Sunshine Act Recently Released

April 16, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Group Purchasing Organizations ("GPO"), Health Care Law, Healthcare Regulation, Sunshine Act

The long-awaited final regulations for the Physician Payments Sunshine Act (“Sunshine Act” or “Act”) were finally released on February 1, 2013. I previously discussed the Sunshine Act (see Here Comes the Sun, Are you Prepared?,10/18/2012), but with the final rule now implemented, providers should take a second look at it and reconsider its implications. More >

OIG 2013 WORK PLAN GIVES DIRECTION FOR PHYSICIANS

April 5, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Electronic Health Records (“EHR"), Medicare, Office of Inspector General of the United States Department of Health and Human Services (OIG)

The government’s health care fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal Year (FY) 2012, up from nearly $4.1 billion in FY 2011. Over the last four years, the administration’s enforcement efforts have recovered $14.9 billion, up from $6.7 billion over the prior four-year period.  During 2012, the Department of Justice (“DOJ”) opened 885 new civil health fraud investigations with 1,023 civil fraud matters pending at the end of the year.  The DOJ also reported a record 647 whistleblower lawsuits and recovered $3.3 billion from lawsuits filed by whistleblowers. On the criminal side, the DOJ opened 1,121 new criminal healthcare fraud investigations with 2,032 healthcare fraud criminal investigations pending at the end of FY 2012.  The DOJ filed criminal charges in 452 cases involving 892 defendants during that time. On the civil side, The Office of Inspector General for the U.S. Department of Health and Human Services (“OIG”) excluded 3,131 individuals and entities from participation in the Medicare and Medicaid programs during FY 2012. As the pursuit of health fraud becomes increasingly profitable reportedly returning $7.90 for every $1 spent, providers should expect to see a continued focus and devotion of resources by the federal government to combat healthcare fraud and abuse.  Likewise, the floodgates appear to be opening for healthcare false claims cases as whistleblower suits are predicted to gain popularity as their success breeds volume increases. More >

Senate Finance Committee Takes an In-Depth Look at Fraud & Abuse

February 28, 2013
Posted In Abuse and Waste, Centers for Medicare & Medicaid Services (“CMS”), Compliance Programs, Department of Health and Human Services (HHS), Fraud, Health Care Fraud, Health Care Law, Medicaid, Senate Finance Committee Report

Earlier this week, I discussed the HHS and DOJ Annual Report for the Health Care Fraud and Abuse Program.  HHS and DOJ are not the only ones who are determined to purge the health care industry of its woes.   On January 31, 2013 a group of six current and former members of the Senate Finance Committee released a comprehensive report detailing recommendations on combating waste, fraud and abuse in the Medicare and Medicaid Programs. More >

Tags: Health Care Law

Annual Report Details Record Breaking Success in Health Care Fraud Prevention

February 26, 2013
Posted In Abuse and Waste, Centers for Medicare & Medicaid Services (“CMS”), Compliance Programs, Department of Health and Human Services (HHS), Fraud, Health Care Fraud, Health Care Fraud and Abuse Control Program, Health Care Law, Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medicaid, Medicare

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), required the establishment of a national Health Care Fraud and Abuse Control Program (“HCFAC”). The HCFAC Program is a joint Department of Justice (“DOJ”) and Health and Human Services (“HHS”) coordination of federal, state and local law enforcement activities to combat fraud committed against all health plans, both public and private. More >

Tags: Health Care Law

CMS 2014 Call Letter: A Bright Future for CMS Star Rating System

February 22, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Health Care Law, Kentucky’s Department for Medicaid Services, Medicaid, Medicare

On February 15, the Centers for Medicare & Medicaid Services (CMS) issued the draft calendar year (CY) 2014 Call Letter for the Medicare Advantage (MA) and Part D programs (Call Letter). It contains information that MA organizations and Part D plan sponsors (collectively, Plan Sponsors) need to prepare their 2014 bids and operations. More >

Tags: Health Care Law

CMS Proposes to Change Physician Requirements for RHC's and FQHC's

February 22, 2013
Posted In Centers for Medicare & Medicaid Services (“CMS”), Federally Qualified Health Centers (“FQHCs”), Health Care Law, Medicaid, Medicare, Patient Protection and Affordable Care Act (“ACA”), Rural Health Centers (“RHCs”)

Since the passage of the Patient Protection and Affordable Care Act of 2010 (“PPACA”), many providers, suppliers and physicians that were enrolled in Medicare and Medicaid were mandated to create compliance programs for their healthcare facilities. Since that time, small and rural providers have been scrambling to adopt and implement programs that can adequately withstand regulatory and law enforcement scrutiny. Larger providers, such as multi-state hospitals, were already equipped with a compliance program. It is the small and rural providers, limited by staff and financial resources, which have had their hands full complying with the new regulatory requirements. More >

Tags: Health Care Law
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