Tag archives: Medicaid

CMS extends deadline for health insurers to file 2018 rate requests; bipartisan group of experts advocates certain health reform initiatives

On August 11, the Centers for Medicare & Medicaid Services sent a memorandum to insurers announcing an extension of the deadline by almost three weeks until September 5 for insurers to file their 2018 rate requests.  Insurers are wrestling with whether to participate in the Affordable Care Act exchanges/marketplaces in 2018, and if so, the … Continue reading

Health care reform discussions continue in U.S. Senate; CMS issues multiple rules relevant to payments to and policies for hospitals, hospices, and skilled nursing facilities

On August 1, Chairman Lamar Alexander (R-Tenn.) and Ranking Minority Member Patty Murray (D-Wash.) of the U.S. Senate Committee on Health, Education, Labor and Pensions announced that the committee will hold hearings the week of September 4th on actions that Congress could take in an attempt to stabilize and strengthen the individual insurance markets in … Continue reading

U.S. Senate rejects health care reform legislation; CMS releases home health proposed rule for CY 2018

Last week the U.S. Senate rejected three health care reform proposals intended to repeal all or parts of the Affordable Care Act (ACA).  On Tuesday, Vice President Mike Pence cast the deciding vote 51-50 for the Senate to begin debate on legislation to repeal significant parts of the ACA.  Later Tuesday evening, however, the Senate … Continue reading

Senate Republican leadership plans vote to begin debate on health care reform legislation; House Budget Committee approves budget resolution; 340B program hearing held

Without enough votes to begin debate on the July 13th version of the “Better Care Reconciliation Act of 2017” on Monday, July 17, Republican leaders in the Senate called for the repeal of the Affordable Care Act (ACA) without an immediate plan to replace the ACA. According to a report issued by the Congressional Budget … Continue reading

DOJ charges 412 individuals in largest healthcare fraud takedown in US history

On Thursday, the DOJ announced charges against 412 individuals for their alleged participation in healthcare fraud schemes involving approximately $1.3 billion in false billings.  This marks the largest national healthcare fraud takedown in U.S. history—topping the DOJ’s announcement of charges against 301 individuals in June 2016. The enforcement actions spanned across 41 federal districts and … Continue reading

U.S. Senate health care reform legislation if enacted into law will make significant changes to the Affordable Care Act

U.S. Senate Republican leadership yesterday released its draft health care reform legislation entitled the “Better Care Reconciliation Act of 2017.” The Senate legislation would retain two key provisions of the Affordable Care Act (ACA):  (i) insurers are prohibited from denying coverage or increasing an individual’s premiums based on a preexisting medical condition; and (ii) young … Continue reading

US Senate returns from recess with Senate Republicans hoping to draft their version of health care reform legislation; members urge HHS to allow charitable assistance programs to provide financial assistance to patients

The US Senate resumes business this week after a week-long recess with Senate Republicans hoping to begin to draft their version of health care reform legislation. Senate Majority Leader Mitch McConnell (R-Ky.) has expressed doubt whether Republicans will have the minimum 50 votes necessary in the Senate to pass the bill. The most significant issues … Continue reading

News from DC – President Trump addresses a Joint Session of Congress and House Republicans revise ACA replacement legislation and schedule hearings

On Tuesday, February 28, President Trump addressed a Joint Session of Congress and outlined his Affordable Care Act (ACA) replacement legislation principles.  The President endorsed a tax credit and expanded Health Savings Accounts to help people purchase health care insurance.  He reiterated that individuals should be able to purchase health insurance across state lines.  The President … Continue reading

Proposed rule strengthens state Medicaid Fraud Control Units

On Tuesday, September 20, 2016, CMS published a proposed rule in the Federal Register to bolster the current State Medicaid Fraud Control Units (MFCUs or Units).  MFCUs investigate and prosecute Medicaid fraud, including provider fraud, patient abuse, and neglect in health care facilities. MFCUs operate in 49 States and the District of Columbia. The MFCUs, … Continue reading

Physicians’ compensation structure results in $17M Stark Law fine and CIA for hospital

Lexington Medical Center (“LMC”), a 428-bed hospital in South Carolina, has agreed to pay $17 million to resolve allegations that it violated the federal False Claims Act (“FCA”), 31 U.S.C. §§ 3729 et seq., and Physician Self-Referral Law (“Stark Law”), 42 U.S.C. § 1395nn, by allegedly providing improper financial incentives to 28 physicians for referrals.… Continue reading

Texas supreme court temporarily halts state Medicaid cuts for home health therapy programs for disabled children

The Texas Supreme Court has temporarily blocked the Texas Health and Human Services Commission’s planned rate reductions for Medicaid home health services for severely disabled children, holding that a temporary injunction issued by a trial court enjoining the rate cuts from taking effect remains binding pending the issuance of a mandate by the Texas Third … Continue reading

2015 CMS “Open Payments” data released

Last week, CMS posted the 2015 Open Payments data to its website, as well as updated payment records for 2013 and 2014.  Overall, manufacturers reported $7.52 billion in payments and ownership interests to 618,931 physicians and 1,116 teaching hospitals in 2015.  Nearly 1,500 companies reported making payments in 2015, comprising a total 11.9 million records.  … Continue reading

CMS proposes rule regarding changes to Medicare appeals procedures

The Centers for Medicare and Medicaid Services (CMS) has promulgated a proposed rule that makes numerous revisions to the appeals process for Medicare claims. If finalized, this proposed rule will mainly clarify the existing regulations regarding the Medicare appeals process. It will, however, also add two key concepts to help streamline the appeals process.  … Continue reading

DOJ charges over 300 people in largest healthcare fraud “takedown” in U.S. history

On Wednesday, the Justice Department announced that it had brought criminal and civil charges against 301 healthcare professionals as part of the largest national healthcare fraud “takedown” in history. A nationwide investigation spearheaded by the Medicare Fraud Strike Force revealed claims amounting to $900 million in the form of alleged kickbacks, money laundering, and other … Continue reading

CMS publishes final rule to update medicare clinical diagnostic laboratory tests payment system for program savings

On June 17, 2016, CMS published the “Medicare Clinical Diagnostic Laboratory Tests Payment System” final rule. Among the key changes in this final rule, CMS has revised the Medicare Clinical Laboratory Fee Schedule (CLFS) such that payment for clinical diagnostic laboratory tests (CDLTs) beginning January 1, 2018 will reflect the weighted median of private payor … Continue reading

OIG finds CMS deficient in monitoring compliance by hospitals with provider-based status requirements

On June 17, 2016, the Department of Health and Human Services’ Office of Inspector General (OIG) released a report entitled “CMS Is Taking Steps to Improve Oversight of Provider-Based Facilities, But Vulnerabilities Remain” (OEI-04-12-00380). The OIG reviewed oversight by the Centers for Medicare & Medicaid Services (CMS) of compliance by hospitals with the Medicare provider-based … Continue reading

New ethical guidelines from the AMA: Telemedicine

On June 13, 2016, the American Medical Association (AMA) at its annual meeting approved new ethical guidelines for physicians providing telemedicine services, which will be incorporated in the full publication of the AMA Code of Medical Ethics this fall. Although the ethical guidelines do not place legal limitations on the provision of telemedicine for any … Continue reading

CMS proposed rule revises conditions of participation for hospitals and CAHs

On June 13, 2016, CMS published a proposed rule intended to revise the conditions of participation (CoPs) required for hospitals and critical access hospitals (CAHs) to participate in the Medicare and Medicaid programs, with a focus on quality of care. Highlights from the proposed rule are outlined in further detail below.… Continue reading

House bill addresses reduced payments to new off-campus hospital outpatient departments

On May 18, 2016, the U.S. House of Representatives Ways and Means Committee introduced the Helping Hospitals Improve Patient Care Act of 2016 (Act) to exempt certain newly-enrolled provider-based, off campus hospital outpatient departments (HOPDs) from reduced payments under the Bipartisan Budget Act of 2015 (BBA).… Continue reading

CMS seeks feedback on standard form for SRDP submissions

CMS has asked for comments on a form for healthcare providers to disclose actual or potential violations of the federal self-referral (Stark) law.  The proposed format includes a disclosure form, a physician-information form, and a financial-analysis worksheet. As many providers know, CMS is significantly backlogged with self-disclosures, and so the standard form may help the agency more … Continue reading