Tag Archives: Medicare

President Obama Signs MACRA: Permanently Reforms Medicare Physician Reimbursement Framework, Includes Other Health Policy Provisions

Today President Obama signed into law H.R. 2, the "Medicare Access and CHIP Reauthorization Act of 2015" (MACRA), which reforms Medicare payment policy for physician services and adopts a series of policy changes affecting a wide range of providers and suppliers. Most notably, MACRA permanently repeals the statutory Sustainable Growth Rate (SGR) formula, achieving a goal that has eluded Congress for years. Now, after a period of stable payment updates, MACRA will link physician payment updates to quality, value measurements, and participation in alternative payment models.… Continue Reading

CMS Announces Medicare Deductible, Coinsurance Amounts for 2015

CMS has released the Medicare Part A inpatient hospital deductible and hospital and extended care services coinsurance amounts for 2015. Specifically, the 2015 Part A deductible for hospital inpatient admissions for the first 60 days of care will be $1,260, followed by $315 per day for days 61-90 and $630 per day for stays beyond … Continue Reading

CMS Corrects Final FY 2015 Medicare IPPS/LTCH Rule

CMS has published corrections to its August 22, 2014 final update to the Medicare Hospital Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System for FY 2015. Among other things, CMS made technical errors in its calculation of the operating and capital IPPS budget neutrality factors, outlier threshold, operating standardized amounts, … Continue Reading

CMS Issues Final Medicare Inpatient Psychiatric Facility PPS Rule for FY 2015

CMS has published a final rule that updates prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs) for FY 2015. Under the final rule, the federal per diem base rate will be increased by 2.1%, reflecting a market basket increase of 2.9%, offset by a 0.3 percentage point reduction and … Continue Reading

Medicare Intravenous Immune Globulin (IVIG) Demonstration Launched

CMS has announced a new “Medicare Intravenous Immune Globulin (IVIG) Demonstration” that will evaluate the potential benefits of providing payment for items and services needed for in-home administration of IVIG for the treatment of primary immune deficiency disease (PIDD). Under this demonstration, which will last three years, Medicare will provide a bundled Part B payment … Continue Reading

MedPAC Issues Medicare Delivery Reform Recommendations

On June 13, 2014, the Medicare Payment Advisory Commission (MedPAC) released its June 2014 Report to the Congress on Medicare and the Health Care Delivery System. Among other things, MedPAC addresses ways to align Medicare fee-for-service (FFS), Medicare Advantage, and accountable care organization policies on payment, risk adjustment, and quality measurement. MedPAC also discusses various … Continue Reading

OIG Proposed Rule Would Expand Civil Monetary Penalty Authority

On the heels of its proposed rule to expand its health program exclusion authority, the Office of Inspector General (OIG) of the Department of Health and Human Services has published a proposed rule that would amend the health care program civil monetary penalty (CMP) regulations. The rule would codify the OIG's expanded statutory authority under the Affordable Care Act to impose CMPs on providers and suppliers and would allow for significant penalties in a variety of scenarios, some of which could extend beyond what is currently permitted. Reed Smith attorneys have prepared a Client Alert summarizing and analyzing the OIG's proposed rule, including the various scenarios under which CMPs could be issued under the proposed regulations, such as: failure to report and return an overpayment; failure to grant OIG timely access to records upon request; ordering or prescribing items or services while excluded from a federal health care program, as well as arranging or contracting with an individual or entity who meets this criteria; making false statements or omitting or misrepresenting material facts in an application, bid, or contract; and failing to submit or certify drug-pricing and product information in a timely manner. In addition, the alert covers the changes in technical language proposed by OIG to clarify and more clearly define the scope of CMP regulations.… Continue Reading

Highlights from Reed Smith’s Post-Acute Care Conference

In early April, Reed Smith hosted an enlightening conference entitled "Reed Smith 2014 Washington Health Care Conference: Focus on Post-Acute Care" in Washington, D.C. The conference brought together a panel of experts to discuss episodic care, bundling models, and alternative payment and delivery systems, as well as other speakers to present from the perspective of investors and Capitol Hill. The conference was capped with a stimulating keynote address from American Enterprise Institute resident scholar Dr. Norman Ornstein on the current polarized nature of American politics, particularly in regards to national health policy.… Continue Reading

Medicare Paper Claims Must Be Submitted on Revised 1500 Form By April 1, 2014

CMS is instructing Medicare providers and suppliers that the updated version of the Medicare claim form (CMS 1500 form version 02/12) must be used for all Medicare paper claims received on and after April 1, 2014. The new form includes indicators to differentiate between ICD-9 and ICD-10 codes, identifies whether certain providers have performed an … Continue Reading

GAO Report Confirms Insurance Coverage Prior to Medicare Linked to Better Health, Lower Program Spending

This post was written by Nancy Sheliga. The Government Accountability Office (GAO) has released a report examining the effect of prior health insurance coverage on Medicare beneficiaries. The report specifically focuses on the health status, program spending, and use of services by Medicare beneficiaries with and without continuous health insurance coverage before Medicare enrollment. According to … Continue Reading

Medicare Appeals Backlog Prompts Hold on New Provider Appeals

Citing a “rapid and overwhelming increase in claim appeals,” the HHS Office of Medicare Hearings and Appeals (OMHA) has temporarily suspended the assignment of most new provider requests for an Administrative Law Judge (ALJ) hearing. In a memorandum to high-volume appellants dated December 24, 2013, Chief ALJ Nancy Griswold announced that the suspension, which was … Continue Reading

OIG Calls for Greater Scrutiny of Clinicians with High Cumulative Medicare Payments

The OIG has issued a report focusing on individual clinicians who generated high cumulative Medicare Part B payments (defined for purposes of this report as more than $3 million in Part B services) in 2009. Out of 303 such clinicians identified by the OIG, 34% had been identified for improper payment reviews, and as of … Continue Reading

House Panel to Examine Medicare “Extenders” Policy

On January 9, 2014, the House Energy and Commerce Health Subcommittee is holding a hearing on “The Extenders Policies: What Are They and How Should They Continue Under a Permanent SGR (Sustainable Growth Rate) Repeal Landscape?” The so-called extenders are measures that secure the continuation of various temporary Medicare payment and policy revisions impacting hospitals, … Continue Reading

CMS Boosts Provider Enrollment Fee for 2014

CMS has announced the 2014 application fee for institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP); revalidating their Medicare, Medicaid or CHIP enrollment; or adding a new Medicare practice location (unless a hardship exemption applies). The fee for 2014 is $542, up from $532 in … Continue Reading

CMS Releases Medicare Deductible, Coinsurance Amounts for 2014

CMS published notices on October 30, 2013 announcing the 2014 Medicare inpatient hospital deductible and hospital and extended care services coinsurance amounts. The 2014 Part A deductible for hospital inpatient admissions for the first 60 days of care will be $1,216, followed by $304 per day for days 61-90 and $608 per day for stays … Continue Reading

Government Shutdown Update: Medicare Claims Processing Continues, but Other Key Functions on Hold

The ongoing partial federal government shutdown that began on October 1, 2013 due to the government funding impasse is having a varied impact on health care provider operations. CMS has ordered Medicare Administrative Contractors (MACs) to continue to perform all Medicare claims processing and payment functions during the government shutdown. Some providers may experience the … Continue Reading

Ways and Means Committee Invites Public Comment on Medicare Cost Sharing Proposals

The House Ways and Means Committee is seeking comments on three bipartisan proposals intended to “modernize” Medicare cost-sharing policies. The proposals, which were included in President Obama’s proposed FY 2014 budget, include: (1) reducing premium subsides for wealthier seniors in Medicare Parts B and D (10-year savings of at least $50 billion); (2) increasing the … Continue Reading

Improper Medicare Payments for Unlawfully Present, Incarcerated Beneficiaries

The OIG has discovered that Medicare has paid millions of dollars in benefits for aliens who are not lawfully present in the country and for incarcerated beneficiaries, contrary to program rules. Specifically Medicare made $91.6 million in payments to health care providers for services to approximately 2,600 unlawfully present beneficiaries during calendar years 2009 through … Continue Reading

Obama Administration’s Regulatory Agenda Points to Busy 2013 for HHS

On January 8, 2013, the Obama Administration published its latest semiannual regulatory agenda, outlining planned regulatory initiatives in a number of policy areas. The Federal Register version of the agenda includes only a portion of the regulations in the pipeline, however; the full agenda has been posted on the Office of Management and Budget (OMB) web … Continue Reading

GAO Calls for Improvements in Use of Medicare Prepayment Edits

In light of a continued high rate of Medicare fee-for-service improper payments (8.6% in FY 2011), the GAO recently assessed the use of Medicare prepayment edits and CMS’s oversight of Medicare Administrative Contractors (MACs) that process claims.  In the report, "Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment," the GAO … Continue Reading

OIG Highlights Vulnerabilities in CMS Oversight of the Medicare EHR Incentive Program

The Medicare electronic health record (EHR) incentive program is vulnerable to paying incentives to professionals and hospitals that do not fully meet meaningful use requirements due to gaps in CMS oversight, according to a recent OIG report. Based on a review of CMS’s oversight of self-reported meaningful use of certified EHR technology in 2011, the … Continue Reading