Topic: Regulatory

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CMS Releases Final Rule on CY 2020 Physician Fee Schedule Updates and Implements Opioid Use Disorder Treatment Programs

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates the Medicare Physician Fee Schedule (PFS) rates and policies for calendar year (CY) 2020 and expands Medicare coverage to opioid treatment programs (OTPs) that treat beneficiaries with opioid use disorder (OUD). In a fact sheet accompanying the … Continue reading

CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) published its CY 2020 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule.  The final rule implements a number of significant changes to payment policies and rates for services furnished to Medicare beneficiaries in hospital outpatient … Continue reading

CMS Issues Final Rule Implementing CY 2020 Home Health Prospective Payment System Updates, Other Policy Changes for Home Health Agencies, and Payment Policies for CY 2021 Home Health Infusion Therapy Services Benefit

On October 31, 2019, the Centers for Medicare & Medicaid Services (CMS) released its final rule with comment period that sets forth updates to the home health prospective payment system (HH PPS) for calendar year (CY) 2020 and includes other policy changes for home health agencies (HHA). This final rule also finalizes payment policies for … Continue reading

U.S. District Court Upholds Ruling that CMS Exceeded Its Statutory Authority in Reducing Medicare Payments for Clinic Visit Evaluation and Management Services Furnished in Hospital Excepted Off-Campus Provider-Based Departments

On October 21, 2019, U.S. District Judge Rosemary M. Collyer denied the government’s request to modify the Court’s previous ruling on September 17, 2019, that the Centers for Medicare & Medicaid Services (CMS) exceeded its statutory authority when it reduced Medicare payment rates for clinic visit evaluation and management (E&M) services provided to Medicare patients … Continue reading

CMS requests comments on the use of new technologies in the Medicare and Medicaid programs

On Monday, October 21, 2019, the Centers for Medicare & Medicaid Services (CMS) posted a request for information (RFI) soliciting comments on the use of new technologies in the Medicare and Medicaid programs. In a blog post accompanying the release of the RFI, CMS Administrator Seema Verma referenced the Government Accountability Office’s designation of “Medicare … Continue reading

CMS and OIG release sweeping proposals to modernize Stark Law and AKS regulations

On Thursday, October 17, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) Office of Inspector General (OIG) will publish in the Federal Register two proposals to implement major changes to Stark Law and Anti-Kickback Statute (AKS) regulations. We have summarized a portion of those proposed … Continue reading

US regulators to align key health care regulations with transformation to value-based care system; CMS and OIG propose major overhaul of Stark Law and AKS regulations

On October 9, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued two sweeping proposals aimed at revising the Stark Law and Anti-Kickback Statute (AKS) regulations to adapt to and promote the US health care system’s transformation to value-based payment … Continue reading

Medicaid Update: D.C. Circuit Court of Appeals Reviews CMS Approval of Medicaid Work and Community Engagement Eligibility Requirements

Today, October 11, 2019, the United States Court of Appeals for the D.C. Circuit is hearing oral arguments in Stewart v. Azar (Case No. 19-5095), an appeal from the federal district court’s rulings invalidating three prior approvals of Section 1115 Waivers in Kentucky and Arkansas that would have implemented work and community engagement requirements as … Continue reading

U.S. District Court vacates CY 2019 OPPS final rule reducing Medicare payment rates for evaluation and management services furnished in hospital excepted off-campus provider-based departments

On September 17, United States District Judge Rosemary M. Collyer, United States District Court for the District of Columbia, ruled that CMS in its CY 2019 OPPS final rule reducing Medicare payment rates for evaluation and management (E/M) services furnished to Medicare beneficiaries in hospital excepted off-campus hospital provider-based departments exceeded its statutory authority and … Continue reading

The Joint Commission releases sentinel event statistics for first six Months of 2019

On August 14, 2019 The Joint Commission (TJC) released sentinel event statistics for the first half of 2019, which included 426 events.  83% of the events were voluntarily self-reported by an accredited or certified organization.  The five most frequently reported sentinel events were: Unintended retention of a foreign body part – 60 Wrong-site surgery – … Continue reading

CMS releases FY 2020 IPPS and LTCH PPS final rule

On August 2, 2019, the Centers for Medicare & Medicaid Services (CMS) published its Fiscal Year (FY) 2020 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System (PPS) final rule (CMS-1716-F). The final rule is scheduled to be published in the Federal Register on August 16, 2019. … Continue reading

CMS Publishes FY 2020 Medicare Hospital IPPS and LTCH PPS Final Rule

On August 2, 2019, the Centers for Medicare & Medicaid Services (CMS) published its Fiscal Year (FY) 2020 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Acute Care Hospital (LTCH) Prospective Payment System (PPS) final rule (CMS-1716-F). The final rule is scheduled to be published in the Federal Register on August 16, … Continue reading

The Joint Commission Issues Sentinel Event Alert on Direct Oral Anticoagulants

On July 30, 2019, The Joint Commission (TJC) issued Sentinel Event Alert 61: Managing the risks of direct oral anticoagulants (“DOACs”).  The alert may be found here.  According to TJC, “anticoagulants have been named second of the top medications involved in error incidents causing death or serious harm.”  Because there are not FDA-approved reversal agents … Continue reading

CMS Publishes FY 2020 Final Rules for Inpatient Psychiatric Facility PPS and Skilled Nursing Facility PPS

On July 30, the Centers for Medicare & Medicaid Services (CMS) published two federal fiscal year 2020 final rules: (i) inpatient psychiatric facilities (IPFs) prospective payment system (PPS) and quality reporting updates; and (ii) skilled nursing facilities (SNFs) PPS and consolidated billing, including updates to the quality reporting program and value-based purchasing program.… Continue reading

CMS Publishes CY 2020 Proposed Rules for Hospital OPPS and ASC, MPFS, and ESRD and DMEPOS Policies and Payments

On July 29, the Centers for Medicare & Medicaid Services (CMS) published three proposed rules for Calendar Year (CY) 2020: Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule; Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule (MPFS); and End State Renal Disease … Continue reading

Texas Attorney General addresses prompt pay requirements for out-of-network emergency services

An Attorney General Opinion (KP-0250) released on May 22 provides that a court would likely find that the deadline provisions in the Texas Insurance Code applicable to Health Maintenance Organizations (“HMOs”) and Preferred Provider Organizations (“PPOs”) relating to prompt payment apply to out-of-network emergency care providers, while the penalty provisions contained do not apply to … Continue reading

CMS publishes draft “Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities”

On May 3, the Centers for Medicare & Medicaid Services (CMS) published its long-awaited draft “Guidance for Hospital Co-location with Other Hospitals or Healthcare Facilities.”  The draft guidance is specific to compliance with the general Conditions of Participation for hospitals (CoPs) and does not address the specific location and separateness requirements that apply to other … Continue reading

The Joint Commission releases sentinel events for 2018

On March 13, 2019, The Joint Commission released Sentinel Event statistics for 2018.  There were 801 sentinel events in 2018, with 87% being voluntarily self-reported.  According to the Joint Commission, it is estimated that less than 2 percent of all sentinel events are reported.  The Joint Commission defines a sentinel event as: Any unexpected occurrence … Continue reading

Centers for Medicare and Medicaid Innovation announces emergency transportation model

On February 14, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat, and Transport (ET3) Model that aims to transform the ambulance system.  Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers will participate in the model.   CMMI believes this model will improve quality and lower costs by reducing hospitalizations and … Continue reading

OIG proposes to eliminate safe harbor protection for drug manufacturer rebates to PBMs; proposes two new safe harbors

On January 31, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a proposed new rule that, if finalized, would eliminate existing protection under the Anti-Kickback Statute (AKS) “discount” safe harbor (42 C.F.R. 1001.952(h)) for drug manufacturers’ rebates to plan sponsors or pharmacy benefit managers (PBMs) acting under contract with plan … Continue reading

Hospital alert: CMS hospital transparency requirements in effect January 1, 2019

On January 1, 2019, all hospitals are required to make public a list of their standard charges.  As a reminder, Section 2718(e) of the Public Health Service Act, as enacted by the Affordable Care Act, requires: “each hospital operating within the United States” to “make public (in accordance with guidelines developed by the Secretary) a … Continue reading

CMS publishes CY 2019 physician fee schedule final rule

On November 2, 2018, CMS published its CY 2019 physician fee schedule final rule.  The final rule implements a number of significant changes to the way practitioners receive reimbursement for items and services provided to Medicare beneficiaries, including: Eliminating the requirement for a practitioner to document the medical necessity of a home visit in lieu … Continue reading

OIG considers new safe harbors and other incentives to promote coordinated care

As part of the Health and Human Services Department’s (“HHS”) “Regulatory Sprint to Coordinated Care” efforts aimed at alleviating unnecessary regulatory barriers to coordinated care while protecting against fraud and abuse, the Office of Inspector General (“OIG”) issued a Request for Information (“RFI”) on August 27, 2018, requesting public input on the following items: Care … Continue reading
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