Category Archives: Medicare & Medicaid

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Uncertainty Surrounds Low Income Pool (LIP) Funding

The Centers for Medicare and Medicaid Services (CMS), in an August 3, 2017 letter to Florida’s Medicaid Director, approved a five-year extension of the State’s 1115 demonstration project, the Managed Medical Assistance Program (MMA). As part of this extension, CMS approved low-income pool (LIP) funding of approximately $1.5 billion annually. The LIP was created in 2005 to support hospitals, county … Continue Reading

Issues and Analysis of the State’s Medicaid Managed Assistance ITN

The recently released Invitations to Negotiate (ITN) for Florida’s Statewide Medicaid Managed Care program (SMMC) parallels in large part the State’s initial procurements that were released in 2012 and 2013. Where the current ITN differs, however, should be of interest to all applicants and associated parties. This blog post addresses several of the more significant changes for consideration and may … Continue Reading

Medicare Fraud Strike Force Strikes Again – in a Big Way

The Medicare Fraud Strike Force initiated its largest ever healthcare enforcement action, charging 412 defendants in July 2017 with approximately $1.3 billion in fraudulent claims. The Strike Force consists of teams that include the Office of Inspector General, the Department of Justice, Offices of the United States Attorneys, the Federal Bureau of Investigation, and local law enforcement, with efforts concentrated … Continue Reading

State Releases Medicaid Managed Care Invitation to Negotiate

Last Friday, July 14, 2017, the Florida Agency for Health Care Administration (AHCA) released its long awaited Invitation to Negotiate (ITN) for State Wide Medicaid Managed Care services. The ITN, one for each of the 11 regions within the state, may be found on the state Vendor Bid System (VBS), the link for which is provided here. This ITN … Continue Reading

Senate Healthcare Bill Released for Public Review

Just over four weeks after the Congressional Budget Office (CBO) released its score of the American Healthcare Act (AHCA), the bill passed by a narrow margin in the U.S. House of Representatives, the U.S. Senate released ‘The Better Care Reconciliation Act of 2017’. Upon initial review, we are providing a quick overview of this proposed legislation. … Continue Reading

The American Health Care Act, the Sequel Receives Its CBO Grade

Perhaps the high fives in the Rose Garden of the White House a few weeks ago may have been a bit premature. On Wednesday, May 24, 2017, the non-partisan Congressional Budget Office (CBO) released its analysis of the revised American Health Care Act (AHCA), and the review contained positive budgetary news, but the overall impact of the bill on health … Continue Reading

The American Health Care Act: Now What Happens?

To great fanfare by both the leadership of the Republican caucus in the House of Representatives (the House) and President Trump, on May 4, 2017, the American Health Care Act (AHCA), the proposed successor/replacement to the Affordable Care Act (ACA), passed the House by a narrow vote of 217-213. Unsurprisingly, no member of the Democratic Party in the House voted … Continue Reading

Medicare Advantage 2018 Rate Announcement

The Centers for Medicare and Medicaid Services (CMS) announced its 2018 Medicare Advantage (MA) capitation rates, with an expected increase of .45 percent, slightly higher than proposed in the advance notice. CMS estimates that MA health plans will realize an increase in revenue of 2.95 percent, reflecting increases in coding acuity and risk adjustment payments. CMS emphasized that the policies … Continue Reading

HHS Publishes a New Rule to Protect Dialysis Patients From Being “Steered” into Private Coverage for the Benefit of Dialysis Centers

On implementing significant, new requirements for Medicare-certified dialysis facilities that make payment of premiums for individual health coverage, on December 14, 2016, the Department of Health and Human Services (HHS) published an Interim final rule with comment period. The regulations become effective 30 days after the date of publication – January 13, 2017, and comments regarding the interim must be … Continue Reading

Now is the Time to Prepare for MACRA: 2017 Will Bring Major Changes to Physician Medicare Reimbursement

MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) is bi-partisan legislation that was enacted to change Medicare reimbursement from being based on the current system of volume of services provided to reimbursement based on the quality of care, as well as value and participation in alternative payment and delivery models. MACRA replaces the Sustainable Growth Formula (SGR), which … Continue Reading

CMS Postpones Pre-Claim Review Demonstration for Home Health Services

The Centers for Medicare & Medicaid Services (CMS) announced that it would postpone the initiation of the CMS Pre-Claim Review Demonstration for Home Health Services (the “Demonstration”) in Florida, which was scheduled to begin in October 2016. The start dates for Texas, Michigan and Massachusetts, which are also part of the Demonstration, have not yet been announced, but were originally … Continue Reading

Former Home Health Agency Owner Sentenced to 20 Years for $57MM Medicare Fraud

The US Department of Justice announced that Khaled Elbeblaswy, the former owner and manager three Miami-area home health agencies, was sentenced to 20 years in prison and ordered to pay $36.4 million in restitution for his role in a $57 million Medicare fraud scheme.… Continue Reading

11th Circuit Awards Humana Double Damages Under Medicare Secondary Payer Act

Humana Medical Plan, Inc. v. Western Heritage Insurance Co., case number 15-11436.

Liability insurers beware, as the 11th Circuit held that Medicare Advantage Organizations (MAO) are entitled to the same rights Medicare itself would have in actions against primary payers for reimbursement of conditional healthcare treatment costs. … Continue Reading

Brief Reprieve Before Hospitals Must Provide Medicare Patients with “Observation” Notices

Hospitals now have additional time before they must meet federal requirements to provide written notice to Medicare patients who are receiving observation services. Congress passed the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) in 2015, in response to patient confusion and complaints related to hospital observation stays. The rules were expected to be effective in … Continue Reading

Federal Court finds “Systemic Failure” in Processing of Administrative Appeals for Medicare Reimbursement Claims

A win for efficiency: The AHA suit may force shorter adjudication times for Medicare administrative appeals. In 2014, the American Hospital Association (AHA), along with three hospital systems, filed suit against the U.S. Department of Health and Human services, alleging that the lengthy adjudication time for administrative appeals of Medicare claim denials caused severe economic harm.  See, American Hospital Continue Reading

New CMS rule clarifies when 60-day overpayment clock starts ticking

Four years after publication of its proposed rule related to reporting and returning overpayments within 60 days, CMS has issued a final rule that responds to comments and provides greater clarity. The published rule is under the Affordable Care Act requirement that providers report Medicare and Medicaid overpayments and return the overpayment within 60 days of the date it was … Continue Reading

CMS Updates Two-Midnight Rule

The Centers for Medicare and Medicaid Services (CMS) has revised the two-midnight rule to create an exception that will allow payment under Medicare Part A for certain medically necessary hospital stays that do not extend across two midnights. The new rule is effective for admissions after January 1, 2016, and permits payment on a case-by-case basis, supported by the admitting … Continue Reading

Identifying Overpayments Under the ACA’s 60-Day Rule Creates Additional Uncertainty in Determining False Claims Act Liability

Under the Affordable Care Act (ACA), healthcare providers that receive an overpayment from Medicare or Medicaid are required to report and return the overpayment to the government within 60 days after the date on which the overpayment was identified (commonly referred to as the “60-day rule”). An overpayment retained after 60 days constitutes an “obligation” for purposes of potential False … Continue Reading

Illinois Enacts Patient Notification Requirement for Observation Stays

Illinois joins a growing number of states to pass laws requiring that hospitals provide notice to patients who are placed under observation status. 210 ILCS 86/6.09b As with the recent federal NOTICE Act, the laws respond to patients not understanding the difference between observation in a hospital bed and inpatient admission. The Illinois law requires a hospital to notify … Continue Reading

Two-Midnight Rule Update

The Centers for Medicare and Medicaid Services (CMS) announced a further delay, through December 31, 2015, of the Recovery Auditors’ (RA) audits of the “Two-Midnight” Rule. Congress previously passed a law delaying enforcement Recovery Audits for the Two Midnight Rule through September 30, 2015. This has now been extended through December 31, 2015 with enforcement audits of suspect non-compliant … Continue Reading

Hospitals Required to Notify Medicare Beneficiaries of Observation Status

The NOTICE Act (Notice of Observation Treatment and Implication for Care Eligibility) has been signed into law as of August 6, 2015. The Act requires hospitals to provide oral and written notice to patients within 36 hours of being placed in observation care (or, upon discharge, if sooner). The notice must explain to patients, in plain language, that they have … Continue Reading

CMS Extends Enrollment Moratorium on Home Health Agencies

The Centers for Medicare and Medicaid Services (CMS) announced that it will once again extend the moratorium on the enrollment of new home health agencies, branch locations and subunits in certain metropolitan areas of Florida, Texas, Illinois, Michigan, New Jersey and Pennsylvania. In Florida, the moratorium continues in effect in Miami-Dade, Broward, and Monroe counties. The table below identifies the … Continue Reading

CMS Publishes Notice of Proposed Rule Making Regarding Stark Law Amendments and Seeks Comment on the Issue of Stark Acting as a Barrier to Healthcare Reform

In early July, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking, amending the Physician Self-Referral Prohibitions, or Stark law. 80 Fed. Reg. 41,909-930 (July 15, 2015). The proposed rule introduces two exceptions to Stark. The first new exception, 42 C.F.R. §411.357(x), allows financial assistance to medical practices so they may be able to recruit … Continue Reading

HHS Announces First Timeline For Medicare Pay Reforms

On Monday, January 26, 2015, the Department of Health and Human Services (“HHS”) announced a timeline for moving physicians and hospitals into new payment systems and tying Medicare reimbursements to quality of care. This will affect hundreds of billions of dollars in Medicare payments (the goals apply to Medicare Parts A and B, which paid out more than $350 billion … Continue Reading

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