On Friday, March 13, 2020, CMS issued blanket waivers under 42 U.S.C. 1320b-5 that impact long term acute care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs) as a result of President Trump declaring a state of an emergency due to COVID-19. The blanket waivers temporarily allow facilities operating inpatient rehabilitation units to exclude patients admitted
The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule that includes several anti-fraud measures and significantly enhances the agency’s authority to exclude new and current providers and suppliers that are identified as posing an undue risk of fraud, waste or abuse. The new measures require providers and suppliers to disclose to CMS upon its request and upon application for initial enrollment or revalidation any “affiliations” or parties who have one or more defined “disclosable events.” The rule went into effect November 4, 2019.
The new rule requires all providers to disclose any current or prior affiliations within the past five years that the provider—or any of its owning or managing employees or organizations—has or had with a current or former Medicare provider with a “disclosable event,” which is triggered by any of the following:
- an uncollected debt to CMS
- current or previous payments suspension from a federal health care program
- current or previously exclusion from healthcare programs
- previous denial, revocation or termination of Medicare, Medicaid or CHIP billing privileges
Time is running short on the opportunity to comment on a proposed rule further increasing transparency in hospital pricing. The rule was released July 29 and was quickly panned by providers and insurers over provisions requiring hospitals to publicly disclose the negotiated rates they have with third-party payers.
Comments on the rule are due September 27, 2019.
Action by the federal government to increase price transparency in health care is not new, of course. Section 2718(e) of the Public Health Service Act (PHS) was added by the Affordable Care Act to require all hospitals to make public, upon request, the standard charges for the items and services they provide. …
Continue Reading Price Transparency in Health Care . . . Panacea or Not
In January of 2019, the Centers for Medicare and Medicaid Services (“CMS”) implemented a helpful change to the signature exception to the Stark Law. In particular, the exception may now be used more than once during a 3-year period for compensation arrangements with the same referring physician.
History of Signature Exception
The signature exception to the Stark Law has undergone several revisions within the past few years. The original version of the exception was implemented by CMS effective October 1, 2008 in response to concerns regarding the potential for significant Stark Law penalties for mere “technical” violations of the statute. The original language in the signature exception provided for a grace period for noncompliance with the signature requirement of many of the compensation arrangement exceptions to the Stark Law, such as the personal service arrangements exception and fair market value exception. In particular, a 90-day grace period was permitted for late signatures that were inadvertent, and a 30-day grace period was permitted for late signatures that were “not inadvertent.” In addition, the exception could only be used once for the same referring physician during a 3-year period. In other words, after the exception was used once by a DHS entity for a late signature on a compensation agreement with a referring physician, any late signatures on other agreements entered into by the DHS entity and the same referring physician during the following 3-year period would trigger a violation of the Stark Law.…
Continue Reading CMS Finalizes Helpful Change to Stark Law Signature Exception
For decades, pundits, policymakers and consumer groups have called for better tools to make health care purchasing decisions easier. Greater cost transparency and clear indicators of quality, they say, would help consumers make the right choices, which would lead to lower costs and better quality care.
If only it were as easy as using Angie’s List: describe the need and up pops the names of local providers, along with comparative information on their performance.
Increasingly, such information and tools are available. But their impact is unclear.
Since 2010, Medicare consumers have had an “Angie’s List” type of resource in Physician Compare, an online service produced by the Centers for Medicare and Medicaid Services (CMS). The website was mandated by the Patient Protection and Affordable Care Act (ACA). It serves a two-fold purpose, according to CMS:…
Continue Reading Physician Quality Measures—Growing Numbers of them, but are they being used?
Hospitals are not happy with CMS’ recent changes to hospital outpatient payments. Two hospital associations and three hospitals claim in a federal lawsuit filed December 4, 2018, that CMS had no authority to change the payment scheme for off-campus provider-based departments (PBDs). The change took effect January 1, 2019, and is estimated to reduce payments to hospitals by $380 million in the first year of a two-year phase-in period.
The plaintiffs, including the American Hospital Association and the Association of American Medical Colleges, are seeking judgment that the payment change is unenforceable as well as preliminary and permanent injunctive relief. The complaint against US Department of Health and Human Services Secretary Alex Azar was filed in the U.S. District Court for the District of Columbia.
The plaintiffs’ assert that the reduced payments threaten patient access to care and harm the providers’ ability to meet the health care needs of their patients, including some of the most vulnerable populations. …
Continue Reading Hospitals React Strongly to CMS’ Changes to Hospital Outpatient Payments
A new rule proposed by the Centers for Medicare and Medicaid Services (CMS) on October 26, 2018, would revise the way the agency validates the risk adjustment data and collects repayments from Medicare Advantage (MA) organizations. With the new methodology, CMS is expecting to return $4.5 billion in savings to the Medicare Trust Fund over 10 years, according to an October 26 CMS news release.…
Continue Reading CMS Issues Proposed Rule Addressing Payment Error in Medicare Advantage, Expects to Recover $4.5 Billion Over 10 Years
Anticipating open enrollment season for coverage in 2019, the Centers for Medicare and Medicaid Services (CMS) released coverage and premium information that will factor into consumer decisions about Medicare and individual commercial plans offered through exchanges. Enrollment and premium trends also inform regulatory and broader policy decisions at both federal and state levels.…
Continue Reading Open Enrollment Update: CMS Releases Benefit and Market Data
A federal court decision to vacate regulations concerning “overpayments” to Medicare Advantage plans has left open questions about the way the government pays the insurers and pending cases brought by the U.S. Department of Justice.…
Continue Reading Court Decision on Overpayment Rule Leaves Uncertain Future for Medicare Payment Methodology and Pending Justice Department Lawsuits
This is the second article in our series on the new “Pathways” rules for Accountable Care Organizations. Our first article in the series can be found here.
The Centers for Medicare and Medicaid Services (CMS) released a report on August 27, 2018, showing Next Generation accountable care organizations (ACOs) produced net savings of $62 million in 2016 while maintaining quality of care. CMS Administrator Seema Verma pointed to the savings as evidence that ACOs taking two-sided risk succeed, according to a CMS press release. …
Continue Reading Performance Report: “Pathways” Rules Help CMS Advance Two-Sided Risk Sharing