Elizabeth Swayne on Centers for Medicare & Medicaid Services (CMS)

CMS Announces Part D Senior Savings Model for Seniors Requiring Insulin

Citing the high cost of insulin as a common barrier to proper diabetes treatment, CMS has announced a new model to allow beneficiaries additional Part D plan options with lower out-of-pocket costs for insulin. Under the Part...more

3/25/2020 / Centers for Medicare & Medicaid Services (CMS) , Health Plan Sponsors , Medicare , Medicare Part D , Pharmaceutical Industry , Prescription Drug Coverage , Prescription Drugs

CMS Finalizes CY 2020 Physician Fee Schedule

On November 1, 2019, CMS released the Calendar Year (CY) 2020 Physician Fee Schedule (PFS) final rule (the Final Rule). The Final Rule updated payment policies, payment rates, and quality provisions for services furnished...more

11/18/2019 / Centers for Medicare & Medicaid Services (CMS) , Final Rules , Health Care Providers , Medicare , Open Payments , Physician Fee Schedule , Physicians

D.C. Circuit Issues Favorable Jurisdictional Decision in Medicare Clinical Laboratory Case

On July 30, 2019, the D.C. Circuit issued a favorable jurisdictional decision on behalf of King & Spalding client the American Clinical Laboratory Association (ACLA), reversing the district court. Accepting ACLA’s arguments,...more

8/12/2019 / Centers for Medicare & Medicaid Services (CMS) , Clinical Laboratories , Judicial Review , Jurisdiction , Medicare

CMS Issues FY 2020 Inpatient PPS and Long-Term Care Hospital PPS Final Rule

On August 2, 2019, CMS issued its annual Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System Final Rule for FY 2020 (the Final Rule). Highlights include...more

8/9/2019 / Affordable Care Act , CEHRT , Centers for Medicare & Medicaid Services (CMS) , Final Rules , Inpatient Prospective Payment System (IPPS) , Inpatient Quality Reporting , Long Term Care Facilities , Medicare , Payment Systems , Psychiatric Hospitals , Wage Index

CMS Increases CLIA Certification Fees By 20% Effective Immediately

CMS recently announced a 20 percent increase to the fees that laboratories must pay when certified under the Clinical Laboratory Improvement Amendments (CLIA) of 1988. This is the first such increase in the last 20 years and...more

1/10/2019 / Centers for Medicare & Medicaid Services (CMS) , CLIA , Clinical Laboratories , Comment Period , Diagnostic Tests , Federal Register , Request For Information

CMS Announces Additional Guidance on State Empowerment and Relief Waiver Concepts

Following up on a Federal Register notice published October 24, 2018, CMS announced additional information relating to State Relief and Empowerment Waivers, also known as “Section 1332 Waivers” on November 29, 2018 (the...more

12/6/2018 / 1332 Waiver , Affordable Care Act , Centers for Medicare & Medicaid Services (CMS)

CMS Releases Final 2019 Outpatient Prospective Payment System Rulemaking, Finalizing Site Neutral Payment Policy for Off-Campus...

On November 2, 2018, CMS issued the 2018 Hospital Outpatient Prospective Payment System (“OPPS”) Final Rule (“Final Rule”) in which it finalized its proposal to pay the lower Physician Fee Schedule (“PFS”) rate rather than...more

11/7/2018 / Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Outpatient Prospective Payment System (OPPS) , Physician Fee Schedule , Physicians

D.C. District Court Issues Favorable Decision in Section 1115 Waiver DSH Case

On September 28, 2018, the United States District Court for the District of Columbia issued a favorable decision for hospitals appealing the CMS Administrator’s disallowance of certain Medicaid section 1115 waiver days from...more

10/8/2018 / 1115 Waivers , Centers for Medicare & Medicaid Services (CMS) , DSH , MACs , Medicaid

D.C. Circuit Says CMS’s Predicate Fact Rule Does Not Apply to Administrative Appeals

Last week, the U.S. Court of Appeals for the District of Columbia Circuit invalidated CMS’s prohibition on appeals of so-called predicate facts. The appeal before the court, described in greater detail below, challenged the...more

7/9/2018 / Administrative Appeals , Centers for Medicare & Medicaid Services (CMS)

Laboratory Group Challenges CMS’s Implementation of Clinical Laboratory Commercial Data Reporting Requirements

On December 11, 2017, the American Clinical Laboratory Association (ACLA) filed suit on behalf of its membership against the Secretary of HHS, challenging the Secretary’s implementation of the Protecting Access to Medicare...more

12/22/2017 / Centers for Medicare & Medicaid Services (CMS) , Clinical Laboratories , Data Reporting , Department of Health and Human Services (HHS) , PAMA , Reporting Requirements

In Targeting Outlier Payment Reconciliation, OIG Calls for an Aggressive Reading of CMS Reopening Regulations

The HHS OIG recently published a report detailing CMS’s and Medicare Administrative Contractor’s (“MACs’”) ongoing issues in the outlier payment reconciliation process. A previous 2012 review identified 465 cost reports that...more

9/28/2017 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Hospitals , MACs , OIG , Reconciliation

CMS Outpatient Advisory Panel Speaks Out Against Planned 340B Cuts

On August 21, 2017, a CMS advisory panel consisting of provider representatives recommended that CMS not finalize its proposed rule to reduce payments for outpatient drugs to hospitals under the 340B Drug Pricing Program....more

8/29/2017 / Centers for Medicare & Medicaid Services (CMS) , Drug Pricing , Outpatient Prospective Payment System (OPPS) , Section 340B

CMS Issues Proposed Rule on Physician Quality Payment Models

In October 2016, CMS issued a Final Rule for the new physician payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA replaced the Medicare Sustainable Growth Rate (SGR) with a new...more

6/26/2017 / Centers for Medicare & Medicaid Services (CMS) , Medicare Access and CHIP Reauthorization (MACRA) , MIPS , Physician Payments , Physicians , Quality Payment Program (QPP) , Sustainable Growth Rate (SGR) , Value-Based Payments

OIG Faults CMS for its Medicare and Medicaid Improper Payment Rates

Under the Improper Payments Information Act of 2002, as amended, the Department of Health and Human Services (HHS) is required to annually report on improper payments and meet certain improvement metrics. In a report...more

6/13/2017 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Medicaid , Medicare , OIG

D.C. District Court Allows Part C Plan to Continue with Challenge of Overpayment Rule

On March 31, 2017, Judge Rosemary Collyer of the United States District Court for the District of Columbia held that plaintiffs UnitedHealthcare Insurance Company et al. (“United”) had standing to challenge CMS’s overpayment...more

4/20/2017 / Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , False Claims Act (FCA) , Health Insurance , Medicare , Medicare Advantage Organizations (MAOs) , Overpayment

D.C. District Court Upholds CMS’s Predicate Fact Three-Year Reopening Limitation

On March 10, 2017, Judge John Bates of the U.S. District Court for the District of Columbia upheld CMS’s three-year cost report reopening limitation, as applied to “predicate fact” determinations. The regulation at issue is...more

3/31/2017 / Amended Regulation , Centers for Medicare & Medicaid Services (CMS) , Consolidated Appeals , Hospitals , MACs , Provider Reimbursement Review Board , Re-Opening Guidelines , Retroactive Application , Secretary of HHS , Trump Administration

White House “Regulatory Freeze” Delays Implementation of Bundled Payment Models

In the February 17, 2017 Federal Register, CMS announced that it will delay implementation of several bundled payment initiatives until March 21, 2017. The Advancing Care Coordination Through Episode Payment Models (EPMs),...more

3/6/2017 / Bundled Payments , Centers for Medicare & Medicaid Services (CMS) , Episode Payment Models (EPM) , Hospitals , Provider Payments , Regulatory Freeze

CMS Finalizes CY 2017 Physician Fee Schedule

On Wednesday, November 2, 2016, CMS issued a final rule (Final Rule) to update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. In the...more

11/9/2016 / Centers for Medicare & Medicaid Services (CMS) , Final Rules , Medicare Access and CHIP Reauthorization (MACRA) , Medicare Part C , Medicare Shared Savings Program , Physician Fee Schedule , Physicians , Telehealth

CMS Releases FY 2017 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final...

On August 2, 2016, CMS released a final rule (Final Rule) with updates to the Hospital Inpatient Prospective Payment System (Hospital IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) affecting...more

8/10/2016 / Administrative Procedure Act , Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , Final Rules , Hospitals , IMPACT Act , Inpatient Prospective Payment System (IPPS) , Inpatient Quality Reporting , Long Term Care Facilities , Medicare , Provider Payments , Two-Midnight Rule , Value-Based Purchasing

Elizabeth Swayne

King & Spalding

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