Tag archives: reimbursement and payment

FCA case involving interpretation of 60 day overpayment rule settles

Last week, the United States and New York announced a settlement with Mount Sinai Health System for $3 million dollars to resolve allegations that Mount Sinai violated the False Claims Act by retaining overpayments for longer than 60 days after identifying them. The settlement is the first of its kind regarding the Affordable Care Act’s … Continue reading

Administrative dispute resolution process is proposed to resolve 340B drug pricing program disputes

On August 11 the Health Resources and Services Administration (HRSA) issued a notice of proposed rulemaking (RIN 0906-AA90) that would implement an administrative dispute resolution (ADR) process that would apply to all drug manufacturers and covered entities that participate in the 340B drug pricing program. The rule if implemented as proposed will establish and implement … 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 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

SCOTUS endorses “implied certification” FCA claims

In a closely watched decision, the U.S. Supreme Court has unanimously endorsed a version of the “implied false certification” theory of liability under the False Claims Act (“FCA”).  In a decision that leaves almost as many questions unanswered as it resolved, the Court held that a material omission on a claim for payment may give … Continue reading

Australia: Review of pharmaceutical reimbursement rules

Background On 25 April 2015, the Minister for Health announced a review of the Guidelines (Guidelines) for Preparing Submissions to the Pharmaceutical Benefits Advisory Committee (PBAC), the body that recommends which products should be reimbursed by Government, and for how much.  The Minister said the review sought to ensure that the PBAC Guidelines are “consistent … 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

FY 2017 Medicare Acute Care Hospital IPPS and LTCH PPS proposed rule policy highlights

On April 27, 2016, CMS published the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rule for fiscal year (FY) 2017 in the Federal Register. Highlights from the proposed rule are explained in further detail below. Completion of Medicare Severity-Diagnosis Related Group (MS-DRG) $11 Billion Overpayment Recoupment … Continue reading

CMS publishes final rule addressing the reporting and returning of self-identified overpayments; detailed post to follow

This morning the Centers for Medicare and Medicaid Services issued a final rule that addresses the obligation of health care providers and suppliers to report and return overpayments by the later of 60 days from the date an overpayment is identified or the due date of any corresponding cost report. According to the CMS Fact … Continue reading

Congressional hearing on the reimbursement of biosimilars draws criticism of CMS’s existing payment policy

On February 4th, the Energy & Commerce Committee’s subcommittee on health held a legislative hearing regarding the implementation of the Biologics Price Competition and Innovation Act, which established a shortened FDA approval process for determining when biosimilar products are considered interchangeable with previously-approved FDA products.  The subcommittee members expressed concerns regarding plans to reduce reimbursement … Continue reading

CMS publishes Medicaid covered outpatient drugs final rule

On January 21, 2016, the Centers for Medicare and Medicaid Services (CMS) published the final rule with comment period titled “Medicaid Program; Covered Outpatient Drugs.” In the final rule, CMS implements provisions of the Affordable Care Act (ACA) pertaining to Medicaid reimbursement for covered outpatient drugs (CODs) and revises key requirements related to the Medicaid … Continue reading

Increased focus on data analysis by government agencies

At a recent DC Bar program called “The Use of Data by the OIG-DHHS and CMS/CPI in Medicare Program Integrity, Investigations and Compliance,” representatives from CMS and the OIG provided their perspectives on the evolving capabilities of government agencies to review and analyze large datasets related to the provision and reimbursement of healthcare services.… Continue reading

CMS issues final rule establishing prior authorization process for certain DMEPOS items

On December 30, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule establishing a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that the government maintains are typically subject to unnecessary utilization (i.e. items that do not comply with Medicare’s coverage, coding, and payment rules). … Continue reading