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Medicare MACs

Foley & Lardner LLP

Medicare: Prescriptions Now May Be Used to Support Medical Necessity of Durable Medical Equipment

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On September 26, 2024, the Centers for Medicare & Medicaid Services’ (CMS) Durable Medical Equipment (DME) Medicare Administrative Contractors (DME MACs), Noridian Healthcare Solutions, LLC and CGS Administrators, LLC,...more

King & Spalding

Transitional Coverage for Emerging Technologies: CMS’s Latest, But Not Necessarily Greatest, Coverage with Evidence Approach

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On August 7, 2024, the Centers for Medicare & Medicaid Services (“CMS” or the “Agency”) issued a final procedural notice (“Notice”) outlining a new Medicare coverage pathway, aimed at achieving timelier and predictable access...more

McDermott+

CMS Releases Final Procedural Notice on Transitional Coverage for Emerging Technology (TCET)

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The Centers for Medicare & Medicaid Services (CMS) issued the final procedural notice on Transitional Coverage for Emerging Technologies (TCET), effective as of August 12, 2024. TCET is a new pathway that uses existing...more

Mintz - Health Care Viewpoints

CMS Issues Final Notice on Program for Breakthrough Device Reimbursement but Industry Looks to Congress for More Inclusive...

Obtaining Medicare coverage and reimbursement for medical devices is notoriously more difficult than for drugs or biologics, and any progress on expanding coverage pathways has been agonizingly slow for industry stakeholders....more

Bradley Arant Boult Cummings LLP

The Overturn of Chevron: A New Design for Healthcare Law

On June 28, 2024, SCOTUS overturned the long-standing Chevron doctrine in its decision Loper Bright Enterprises v. Raimondo and Relentless v. Department of Commerce. The Court’s ruling will have a significant impact on...more

McDermott+

McDermottPlus Check-Up: February 16, 2024

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House Energy and Commerce Health Subcommittee Holds Legislative Hearing on 19 Bills. Lawmakers discussed 19 pieces of legislation designed to support patients and caregivers in the key areas of autism, heart defects,...more

McDermott+

No Congressional Doc Fix on the Immediate Horizon: What Happens Next?

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Congress is on its way to extending the stop-gap funding bills into March (and may have already done so by the time you read this). Absent from the legislation to continue funding the federal government is a “doc fix” that...more

Venable LLP

A Proposed New Regulatory Environment for Medicare Hospice Providers: Application of the 36-Month Rule, Increasing Enrollment...

Venable LLP on

On July 10, 2023, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) that would (i) include hospices in the 36-month rule ownership transfer restrictions that currently exist for home...more

Holland & Knight LLP

CMS Proposes Transitional Coverage for Emerging Technologies

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The Centers for Medicare & Medicaid Services (CMS) recently issued a long-awaited Notice with Comment Period outlining a proposed Transitional Coverage for Emerging Technologies (TCET) pathway under Medicare that would be...more

King & Spalding

CMS Review Choice Demonstration for Inpatient Rehabilitation Facility Services Beginning in August 2023

King & Spalding on

On June 27, 2023, CMS hosted a Special Open Door Forum regarding its Review Choice Demonstration program for Inpatient Rehabilitation Facility Services (IRFs). CMS has stated that the Medicare IRF benefit continues to...more

Sheppard Mullin Richter & Hampton LLP

CMS Takes Steps to Lower SNF Medicare Payment Error Rates

With the Medicare Comprehensive Error Rate Testing program projected error rate for skilled nursing facilities (SNFs) showing a significant increase in 2022 (15.1%, up from 7.9% in 2021), the Centers for Medicare and Medicaid...more

McDermott+

Remote Monitoring Services Under Review: Update on Potential Medicare Coverage Policies (May 2023 Update)

McDermott+ on

On May 19, 2023, Novitas Solutions and First Coast Options sent an email to certain interested parties, with whom they had engaged following the multijurisdictional contractor advisory committee (CAC) meeting explaining that...more

Health Care Compliance Association (HCCA)

MA Final Rule: CMS Requires Two-Midnight Rule, Puts Limits on Internal Coverage Criteria

In what passes for neon lights in the regulatory world, CMS said Medicare Advantage (MA) plans must follow the two-midnight rule, its case-by-case exception and the inpatient-only (IPO) list, according to the final 2024 rule...more

Foley & Lardner LLP

Medicare Compliance Basics: “Incident to” Billing

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Editor’s Note: We are excited to announce that this article is the first of a series addressing Medicare Part B’s “incident to” billing requirements, designed to give practical guidance and orientation to health care...more

Bass, Berry & Sims PLC

CMS Audits: Part 1 The ABCs of Medicare and Medicaid Claims Audits: Understanding the Audit Contractors

Bass, Berry & Sims PLC on

Because Medicare and Medicaid claims audit requests can look like routine billing-related correspondence, they can be easy to miss, leading to expensive and potentially catastrophic consequences. Providers, therefore, should...more

King & Spalding

OIG Audit Finds That Providers Did Not Always Comply with Federal Requirements When Claiming Medicare Bad Debts

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This month, OIG published its findings relating to its audit on providers who sought reimbursement from Medicare for bad debts. OIG conducted the audit to confirm whether: (a) providers complied with Federal requirements...more

King & Spalding

GAO Releases Report and Recommendations to CMS to Address Risks Posed by Provider Enrollment Waivers and Flexibilities Implemented...

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On December 19, 2022, the U.S. Government Accountability Office (GAO) released a report titled, “Medicare: CMS Needs to Address Risks Posed by Provider Enrollment Waivers and Flexibilities” (GAO-23-105494). The report...more

Nelson Mullins Riley & Scarborough LLP

More on Understanding the Medicare Overpayment Appeals Process

The initial article on this subject discussed generally why Medicare providers need to understand the Medicare administrative appeals process, especially in connection with overpayment determinations, Additional Documentation...more

Verrill

2021 Medicare Cost Report Preparation, Reminders and New Developments for Hospitals

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With many hospitals well into their FY 2021 Medicare cost report preparation, here is a brief reminder of the process required for protesting items, as well as a summary of two new developments for Medicare Graduate Medical...more

Baker Donelson

CMS Budget Justification Requests Increased Audit and Appeals Funding

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The Centers for Medicare & Medicaid Services' (CMS) FY 2022 Budget Justification request to Congress suggests an increased focus on Medicare claim reviews and an effort to decrease the number of claim denials overturned...more

Maynard Nexsen

SMRC Intensified Auditing in 2021: What is a Supplemental Medical Review Contractor and What Are They Auditing?

Maynard Nexsen on

The year 2020 saw much less medical review auditing, including a CMS suspension of audits between March 30 and August 3 of 2020. However, with the lifting of the CMS suspension, the CMS Supplemental Medical Review Contractor...more

Oberheiden P.C.

5 Defense Strategies for MAC/RAC Audits

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Medicare pays billions of dollars in fraudulently billed claims each year despite the various tools the Medicare system has at its disposal. Because of this problem, the Centers for Medicare and Medicaid Services (“CMS”)...more

Baker Donelson

CMS Issues Proposed Retroactive DSH Rule Requiring Medicare Part C Days in the Medicare Fraction and Blocks Providers' Appeals...

Baker Donelson on

In a Federal Register publication last month, CMS announced that it intended to retroactively adopt a change to its Medicare disproportionate share hospital (DSH) regulation. Specifically, it proposed adopting a 2014 change...more

Foley & Lardner LLP

COVID-19: OIG Announces Review of Hospital Payment Increase

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The Office of Inspector General (OIG) for the Department of Health and Human Services recently announced a new addition to its work plan: auditing whether payments made by Medicare for COVID-19 inpatient discharges billed by...more

Arnall Golden Gregory LLP

OIG Weighs-In on the Review of Extrapolated Overpayments in the Medicare Appeals Process

The financial stakes are often very high for providers when statistical sampling and extrapolation is used to calculate an alleged Medicare overpayment. In post-payment audits involving extrapolation, an actual claims denial...more

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