In a June 23, 2020 decision, Judge Nichol of the United States District Court for the District of Columbia ruled in favor of the Center for Medicare and Medicaid Services (“CMS”) and against the plaintiff hospital...more
On November 15, 2019, CMS issued a final rule that requires hospitals to disclose to patients the hospital’s “standard charges,” which include the reimbursement rates the hospitals negotiate privately with insurers. This rule...more
On March 30, 2020, CMS through its blanket 1135 waiver authority implemented a “Hospital without Walls” policy to allow hospitals to provide and bill for hospital services in other healthcare facilities and sites, such as...more
On July 29, 2019, CMS released its proposed outpatient prospective payment system (“OPPS”) rule outlining a variety of changes it may implement for calendar year 2020. One proposal that has inspired immediate reactions from...more
8/6/2019
/ American Hospital Association ,
Anti-Competitive ,
Comment Period ,
Disclosure Requirements ,
Health Care Providers ,
Hospitals ,
Medicare ,
Outpatient Prospective Payment System (OPPS) ,
Price Transparency ,
Proposed Rules ,
Public Comment
On July 12, 2018, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule (“Proposed Rule”) that would, among other changes: (1) reduce the documentation requirements with which physicians and other...more
Recent activities of the Department of Justice (“DOJ”) and Qui Tam whistleblowers reveal that Medicare Advantage Plans remain at the forefront of investigations for violations of the federal False Claim Act (“FCA”) for...more
6/12/2017
/ Centers for Medicare & Medicaid Services (CMS) ,
Department of Justice (DOJ) ,
False Claims Act (FCA) ,
Florida ,
Health Insurance ,
Healthcare Fraud ,
Medicare ,
Medicare Advantage ,
Personal Liability ,
Qui Tam ,
Risk Adjustment Formula
As reported in earlier blogs, the federal Department of Justice (DOJ) has been actively looking into potential abuses by Medicare Advantage (MA) Organizations as to allegedly improper risk adjustment claims submissions and...more
5/26/2017
/ Aetna ,
Centers for Medicare & Medicaid Services (CMS) ,
CIGNA ,
Department of Justice (DOJ) ,
False Claims Act (FCA) ,
Government Investigations ,
Health Insurance ,
Health Net ,
Healthcare Fraud ,
Humana ,
Medicare Advantage ,
Qui Tam ,
Risk Adjustment Formula ,
UnitedHealth
With all the talk of the Affordable Care Act’s uncertain future, it is easy to forget about the Medicare Access and CHIP Reauthorization Act (“MACRA”), a bipartisan law passed by Congress in 2015 to change the way physicians...more
Since 2014, there has been a steady increase in mergers and acquisitions in the Rehabilitation sector, with a total of 40 deals announced in 2016. This is almost double the number of deals in 2014 (a total of 21), and...more
In our prior blog post, we reported that, at the request of the federal Department of Justice, the FCA qui tam whistleblower lawsuit in the case of United States ex rel Benjamin Poehling v. United HealthGroup, Inc., et. al....more
WHO IS AT RISK -
The federal government has indicated that it is still investigating, and could ultimately join a false claims whistleblower qui tam action against Aetna, Inc., Humana, Inc., Cigna, Inc. (through its Bravo...more
In a court decision last year in Swoben v. United Healthcare, the United States Court of Appeals for the Ninth Circuit held that an allegation – that a Medicare Advantage Plan performed a “biased” HCC-RAF retrospective...more
Seema Verma’s nomination to head the Centers for Medicare and Medicaid Services (CMS) places Section 1115 Medicaid demonstration waivers into increasing spotlight. This article explores some of the current applications of...more
CMS has recently approved five-year extensions for Medicaid Demonstration Waivers under Section 1115 of the Social Security Act in New York and Arkansas. Both extensions allow each state to continue innovative pilot...more
In 2010, the Affordable Care Act (“ACA”) enacted new rules governing overpayments made by the Medicare and Medicaid programs. Under these rules, providers have 60 days from the date that the overpayment has been identified to...more
7/14/2016
/ 60-Day Rule ,
Affordable Care Act ,
Centers for Medicare & Medicaid Services (CMS) ,
False Claims Act (FCA) ,
False Implied Certification Theory ,
Health Care Providers ,
Medicaid ,
Medicare ,
Medicare Part A ,
Medicare Part B ,
Overpayment ,
Overpayment Recovery Time Limits ,
Universal Health Services Inc v United States ex rel Escobar