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Showing 62 posts in Medicare.

The False Claims Act - the Basics Every Provider Should Know, Part Two

By Anne-Tyler Morgan on June 18, 2015
Posted In False Claims Act, Medicaid, Medicare, Qui Tam

On Tuesday, we discussed the history and basic elements of a violation of the False Claims Act. Today’s post will explore the penalties and enforcement of the Act. More >

The False Claims Act – the Basics Every Provider Should Know, Part One

By Anne-Tyler Morgan on June 16, 2015
Posted In False Claims Act, Medicaid, Medicare, Qui Tam

The federal False Claims Act (“FCA”)[1] casts an incredibly long shadow, covering every transaction between the federal government and a private party seeking payment from it. Enacted at the height of the Civil War in 1863, the law was designed to keep military suppliers honest in their dealings with a government already strapped from fighting a war. Since then, the FCA has served as an almost nuclear deterrent to those who would attempt to defraud the government when requesting payment for services. In 2014, the Department of Justice managed to recover $5.69 billion under the law. False claims in federal healthcare programs accounted for $2.3 billion of that figure, which makes the FCA, as well as its interaction with other laws such as the Affordable Care Act, fraught with difficulty for unwary healthcare providers. More >

Pharmacists: Aren’t you really providers already? - Part One

By Lisa English Hinkle on April 21, 2015
Posted In Accountable Care Organizations (“ACO”), Affordable Care Act, HPSA, Medicare, Patient Protection and Affordable Care Act (“ACA”)

While the passage of the Patient Protection and Affordable Care Act (“ACA”) ushered in a new era of access to health care, it only served to exacerbate a growing crisis in the provision of health care – lack of providers. As of April 2015, the Health Resources and Services Administration lists the population of the United States that lives within a health professional shortage area (“HPSA”) for primary care as 103,847,716, with 1,023,989 of those living in Kentucky.[1] This shortage calls for a reimagining of ways that non-physician providers can fill the care gap, and the debate surrounding the provider status of pharmacists with regard to federal health care programs is evidence of a changing mindset. More >

Five Things to Know about Transitional Care Management

April 16, 2015
Posted In Federally Qualified Health Centers (“FQHCs”), Medicare, Rural Health Centers (“RHCs”), Telehealth

Tuesday’s post discussed the basics of Transitional Care Management (“TCM”), but today’s post will focus on five things that providers should know about TCM. More >

HEALTHCARE NEWS ALERT: Congress Passes Repeal of Sustainable Growth Rate

April 15, 2015
Posted In Medicare

In a 92-8 vote on Tuesday, the Senate passed a bipartisan measure to repeal the Medicare payment formula known as the Sustainable Growth Rate. This bill was part of a deal negotiated in the House between House Speaker John Boehner and Minority Leader Nancy Pelosi in March, and it was approved with equally overwhelming numbers in that chamber. President Obama is expected to sign the legislation, which prevents health care providers from receiving a 21 percent cut in Medicare reimbursement rates. The bill will also fund the Children’s Health Insurance Program and community health centers for two further years.  To pay for the bill, high-income seniors will cover more of their Medicare costs out of pocket, and Medigap plans will require basic co-payments. More >

Five Key Elements of Transitional Care Management

April 14, 2015
Posted In Centers for Medicare & Medicaid Services (“CMS”), Medicare

Similar to rules providing billing opportunities for chronic care management (as discussed in this McBrayer blog post), relatively new Medicare funds for Transitional Care Management (“TCM”) provide a new path for providers to supplement their Medicare practice with payment for services they may already provide. Beginning in 2013, Medicare, for the first time, allowed providers to bill for thirty days of TCM, incentivizing post-discharge care with an aim to prevent hospital readmission. The Center for Medicare and Medicaid Services (“CMS”) requires five specific elements of TCM to be met before provider reimbursement. Those elements merit review and brief discussion today, while Thursday’s post will discuss five important points of consideration with regard to TCM. More >

Important Recommendations from the MedPAC March Report to Congress, Part Two

By Christopher J. Shaughnessy on April 2, 2015
Posted In Medicare, Part D

Important Recommendations from the MedPAC March Report to Congress, Part Two More >

Important Recommendations from the MedPAC March Report to Congress, Part One

By Christopher J. Shaughnessy on March 31, 2015
Posted In Accountable Care Organizations (“ACO”), Fee for Service, Medicare, Part D

Medicare. Medical Concept.Each March, the Medicare Payment Advisory Commission (“MedPAC” or the “Commission”) is tasked with reporting to Congress on the current state of the Medicare fee-for-service (“FFS”) payment systems, the Medicare Advantage (“MA”) program and the Medicare prescription drug program (“Part D”). This report gives lawmakers recommendations on ways to improve and enhance the Medicare system, as well as shore up areas of concern. This year’s report again struck at the root of systemic problems, specifically noting that an increasing issue within Medicare is a fundamental problem with FFS payment systems – the system incentivizes the delivery of more services without taking into account the value of those additional services. Several reforms in the report are the subject of current Congressional legislation as well. In the posts for both today and Thursday, we’ll parse the various statements and recommendations in MedPAC’s March report with an eye for their effect on the workings of the system. More >

Should Health Care Providers Pay Attention to the Seventh Circuit’s New Definition of “Referral”? - Part One

By Anne-Tyler Morgan on March 24, 2015
Posted In Anti-Kickback Statute, Medicare

The Seventh Circuit Court of Appeals, in the case of United States v. Patel[1], just expanded the definition of “referring” under the federal Anti-Kickback Statute[2] (“Statute”). In light of this case, health care providers should again review any arrangements with their peers and colleagues, as previous arrangements may now be considered illegal under the Statute. More >

CMS Rule on Medicare Overpayments? Don’t Hold Your Breath

March 12, 2015
Posted In Centers for Medicare & Medicaid Services (“CMS”), False Claims Act, Medicaid, Medicare, Patient Protection and Affordable Care Act (“ACA”)

Since the Center for Medicare & Medicaid Services proposed a rule three years ago suggesting that providers could be liable for returning Medicare overpayments going back ten years, providers have been anxiously awaiting a final ruling. Unfortunately, providers’ anticipation for a final ruling will have to continue. On February 16th, CMS announced that it would delay the final rule on reporting and returning overpayment…by another full year! More >

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