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Representatives Jackie Speier (D-California) and Dina Titus (D-Nevada) have introduced HR 2143, the Promoting Integrity in Medicare Act of 2019 (PIMA), which – if enacted – would narrow the “Stark” law’s exceptions and have a direct impact on the services provided by physicians who self-refer for the performance of certain designated health services. The 2019…

As part of its “Regulatory Sprint to Coordinated Care,” the Centers for Medicare & Medicaid Services (CMS) is seeking input on how it can address “unnecessary obstacles to coordinated care, real or perceived, caused by the physician self-referral law.” CMS Administrator Seema Verma acknowledged in a recent blog post that “[i]n its current form, the…

The House Ways and Means Committee has approved legislation to create an alternative pathway to resolve certain technical violations of the Stark physician self-referral law. The bill, HR 3726, would allow an entity or individual to voluntarily disclose previous inadvertent technical noncompliance (e.g., the arrangement is not signed by one or more parties to…

While the Capitol Hill spotlight is focused on the Senate debate on legislation to repeal or revise the Affordable Care Act, the House of Representatives quietly approved by voice vote HR 3178, the Medicare Part B Improvement Act of 2017. The bipartisan bill would impact a number of Medicare policies, including the Stark physician self-referral law, home infusion therapy and dialysis service policies, and documentation requirements for orthotics and prosthetics. In particular, the bill would:
Continue Reading With All Eyes on Senate ACA-Repeal Debate, House Passes Bill to Tweak Stark Law and Other Medicare Part B Policies

CMS has released a new Self-Referral Disclosure Protocol (SRDP) Form for disclosing actual or potential violations of the physician self-referral law (known as the “Stark Act”) under CMS’s existing self-disclosure process. According to CMS, the streamlined and standardized format “will reduce the burden on providers and suppliers submitting disclosures to the SRDP” and facilitate CMS…

The Government Accountability Office (GAO) is out with the latest installment of its “High-Risk Series,” which identifies federal programs “that are especially vulnerable to waste, fraud, abuse, and mismanagement, or that need transformative change.” Once again, GAO flags Medicare and Medicaid as high-risk programs.

With regard to Medicare, GAO notes that while Congress,…

The Centers for Medicare & Medicaid Services (CMS) has issued its final Medicare physician fee schedule (MPFS) for calendar year (CY) 2017.  In addition to updating MPFS rates and policies, the final rule makes numerous other Medicare policy changes, including updates to Stark Law regulations related to unit-based compensation and new enrollment requirements for providers and suppliers furnishing services to Medicare Advantage (MA) enrollees.  Highlights of the rule include the following:
Continue Reading CMS Publishes Final Rule Updating 2017 Medicare Physician Fee Schedule Rates and Policies

CMS has published a notice inviting comments on a revised Medicare Self-Referral Disclosure Protocol (SRDP), which is a vehicle for providers and suppliers to voluntarily self-disclose actual or potential violations of the physician self-referral statute (known as the “Stark Act”).  Under the currently-approved process, a party must provide a financial analysis of overpayments arising from …

Today the Centers for Medicare & Medicaid Services (CMS) published the final rule to update the Medicare physician fee schedule (MPFS) for calendar year (CY) 2016. Despite the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) establishing a 0.5% conversion factor (CF) update for 2016, the final 2016 CF of $35.8279 actually is a decrease compared to the 2015 CF of $35.9335. This is because CMS has more than offset the 0.5% MACRA update with a -0.02% budget neutrality adjustment in addition to a -0.77% “target recapture amount” to reach a statutory target for savings achieved from misvalued code adjustments (discussed below). Final rates and policies are effective January 1, 2016, with certain exceptions. CMS is accepting comments until December 29, 2015 on a limited number of provisions of the rule (e.g., interim final work, practice expense, and malpractice RVUs; interim final new, revised, potentially misvalued HCPCS codes; and changes to the physician self-referral list of codes). The sweeping rule includes numerous policy provisions, including the following:
Continue Reading CMS Finalizes Medicare Physician Fee Schedule Rates, Policies for 2016

On July 15, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to update the Medicare physician fee schedule (MPFS) for CY 2016 – the first rulemaking since the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the sustainable growth rate (SGR) formula.  Under the proposed rule, the 2016 MPFS conversion factor (CF) would be $36.1096, compared with the 2015 CF of $35.9335, reflecting a 0.5% update factor specified under MACRA and a budget neutrality adjustment of 0.9999.  Note that the CF is subject to change in the final rule, however, if CMS does not meet a statutory target for expenditure reductions related to its review of misvalued procedures (discussed below). The proposed rule addresses numerous aspects of Medicare Part B and other CMS program policies.  Highlights include the following: 
Continue Reading Proposed CY 2016 MPFS Rule Takes First Steps in Implementing MACRA Reforms

Today the OIG and CMS published a joint notice continuing the effectiveness of fraud and abuse law waivers granted in 2011 in connection with the Medicare Shared Savings Program, which is intended to encourage physicians, hospitals, and certain other types of providers and suppliers to form accountable care organizations (ACOs). 

By way of background, …

The GAO recently examined “self-referral” for outpatient physical therapy (PT) services, which the GAO defines as a provider referring patients to entities in which the provider or the provider’s family members have a financial interest. According to the GAO, non-self-referred PT services per 1,000 Medicare FFS beneficiaries increased by 41% from 2004 to 2010, while…