Archives: Reimbursement

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Managing MACRA – Part VI: What do I have to do if I’m a specialist?

Specialists are generally subject to the MACRA merit-based incentive payment system (MIPS) in the same manner as primary care clinicians but are treated differently under MACRA in two situations: Certain specialists may qualify as “non-patient-facing” (for example, pathologists or radiologists that do generally not see patients) and have reduced MIPS reporting obligations; and A specialist … Continue Reading

Managing MACRA – Part V: What do I have to do if I’m in an ACO?

As of January 2016, there were 433 Medicare Shared Savings Program (MMSP) Accountable Care Organizations (ACOs) with almost 7.7 million assigned beneficiaries and more than 14,000 participants (a participant may be a group or an individual). Most of these ACOs are one-sided model ACOs that may generate shared savings and do not involve shared losses (Track … Continue Reading

Managing MACRA – Part IV: When does it begin?

Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to eligible clinicians (generally a physician or mid-level – see our previous blog post for details) and most clinicians who treat Medicare patients are expected to be included in MIPS. As a result, one of the most common questions about MACRA is when it starts. CMS’s … Continue Reading

Managing MACRA – Part III: What is an APM?

Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician (generally a physician or mid-level – see our previous blog post for details) except in certain circumstances. One of the circumstances in which an eligible clinician is excluded from MIPS is when the clinician participates in an advanced alternative payment model … Continue Reading

Managing MACRA – Part II: Does MACRA apply to me?

MACRA is making big changes to Medicare clinician reimbursement, so which clinicians are affected? Under MACRA, the merit-based incentive payment system (MIPS) automatically applies to an eligible clinician except in certain circumstances. A MIPS Eligible Clinician (defined at 42 C.F.R. §414.1305) is a: physician, including: (1) a doctor of medicine or osteopathy; (2) a doctor … Continue Reading

How much does it cost to identify and repay federal health plan overpayments late?

Roughly $2.95 for each $1 overpaid (plus legal costs and the overpayment) based on an August 24, 2016, U.S. Attorney’s Office press release regarding settlement of State of New York, ex rel. Robert P. Kane v. Healthfirst, Inc. et al case in the U.S. District Court for the Southern District of New York. Defendants previously … Continue Reading

Out-of-network still in business

The out-of-network (OON) business model faces challenges as the result of changes to health and benefit plan OON coverage, but a ruling by Judge Hoyt of the U.S. District Court for the Southern District of Texas suggests that health plans should be careful in refusing payment based on perceived OON high charges, questions about OON … Continue Reading

CMS’ quest for quality – proposed merit-based and alternative payment model rules released

On April 27, 2016, the Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS) released its proposed rule regarding models for tying professional reimbursement to quality. While this may be great news for providers who enjoy the challenges of tracking and reporting data, these challenges are going to cause problems (namely, reimbursement … Continue Reading

Summary of the final HHS rule for reporting and returning of overpayments

On Feb. 12, the Department of Health and Human Services’ (“HHS”) Centers for Medicare & Medicaid Services (“CMS”) published its final rule regarding reporting and returning Medicare overpayments. This final rule comes nearly four years after its proposed rule regarding the reporting and return of Medicare overpayments that left the provider community nervous and uncertain about … Continue Reading

CMS to rewrite the rules of EHR meaningful use

Recent remarks made by the Centers for Medicare & Medicaid Services (“CMS”) Acting Administrator Andy Slavitt at a healthcare conference indicated that CMS will be ending the “meaningful use” electronic health record (“EHR”) Incentive Program in 2016, five years ahead of its original final end date of 2021. Acting Administrator Slavitt did not elaborate on the … Continue Reading

Physician compensation caution

The U.S. Department of Health & Human Services Office of Inspector General (OIG) issued a special fraud alert on June 9, 2015, stating that physician compensation arrangements may result in significant liability. Hopefully this is not a surprise to any physician or entity that treats federal health plan beneficiaries. However, given that, historically, OIG regulatory … Continue Reading

Update: Texas Medicaid 'incident to' rule now in effect

The Texas Health & Human Services Commission’s (HHSC) final rules regarding physician billing for services provided by an APRN or PA became effective Jan. 1, 2015, and include limitations on such billing arrangements. See 39 Tex. Reg. 9884 (Dec. 19, 2014). The adopted rule requires that a physician billing for services provided by an APRN or PA … Continue Reading

HHS makes moves toward value-based payments

On Jan. 26, 2015, Secretary Sylvia M. Burwell announced the goals and a timeline of the U. S. Department of Health & Human Services (“HHS”) to move the Medicare program, and the healthcare system at large, toward paying providers based on quality, rather than quantity, of care they give to patients.… Continue Reading

DOJ intervenes in first False Claim Act case involving ACA '60-day repayment provision'

The U.S. Department of Justice (DOJ) and the New York State Attorney General intervened in a federal False Claims Act (FCA) case on June 27, 2014, accusing Mount Sinai Health System of failing to report and return Medicaid overpayments within 60 days of identifying them. See U.S. ex rel Kane v. Healthfirst, Inc., et al., No. … Continue Reading

Caveat Emptor: Key Due Diligence Considerations for Hospitals

In a recent article in Health Value Digest, Tiffany Hetland explored two items a hospital should have on its checklist when acquiring a physician practice: a billing and coding audit and a review of documentation practices.  The article is below. Hospital acquisitions of physician practices have been on the rise for some time. At the … Continue Reading

CMS Clarifies Rules Regarding Respite Care, Vaccines for Hospice Patients

This article was originally published by the American Health Lawyers Association. Copyright 2014, American Health Lawyers Association, Washington, DC.  Reprint permission granted. On February 5, CMS issued Change Request 8569 instructing Medicare administrative contractors (MACs) to implement system edits to prevent payment of respite care for more than five days at a time for any hospice claim submitted … Continue Reading

Congress Proposes SGR Repeal and Medicare "Fix"

On Thursday, February 6, 2013, three congressional committees—the Senate Finance, House Ways and Means and House Energy and Commerce—introduced collaborative bipartisan legislation to repeal the sustainable growth rate (SGR), Medicare’s controversial physician payment formula, and replace it a system based on value versus volume of care. Although the committees agreed on policy, the lawmakers did … Continue Reading

Joe Geraci Weighs In on Whether QHPs will be Considered Health Plans

Husch Blackwell attorney Joe Geraci was recently quoted in an AIS Health Reform Week article titled HHS’s Statements on Exchange QHPs Stir Confusion, Complicate Copay Assistance.  The article reports that the Obama administration is sending mixed messages on whether Qualified Health Plans (QHPs) on the insurance exchanges will be considered federal health programs.  A recent … Continue Reading

DSH Program Takes a Hit Under Healthcare Reform

Pursuant to the Affordable Care Act, the Centers for Medicare and Medicaid Services recently adopted a final rule implementing $1.1 billion in cuts to the Medicaid disproportionate share hospital (DSH) program in 2014 and 2015.  The new rule reduces Medicaid DSH payments by $500 million in 2014 and $600 million in 2015.  There are several … Continue Reading

Texas Governor Reigns in HHSC Inspector General

On June 14ththe Governor signed into law SB 1803. It amends Chapter 531 by limiting the Texas Health and Human Services Office of Inspector General’s (HHSC-OIG) ability to implement payment holds, improving providers’ rights to expedited appeals before the State Office of Administrative Hearings, redefining the liability for hearing costs, creating new requirements for HHSC-OIG … Continue Reading

Physician Payments Sunshine Act

On February 1stthe long overdue final rule of the Sunshine Act was released.  The Act aims to increase transparency relating to payments and investments held by physicians and teaching hospitals.  For those many physicians who have entered into some type of contractual relationship with a manufacturer, taking the time to familiarize themselves with these new … Continue Reading