In addition to the key health care provisions included in the Consolidated Appropriations Act of 2021 (Stimulus Legislation) summarized in Baker Donelson's recent publication, the new legislation includes a few additional...more
From the early days of the Medicare program, Medicare has had in place rules allowing payment for Medicare "bad debt" – that is, uncollected deductible and coinsurance amounts associated with a Medicare beneficiary's receipt...more
Among the many provisions in the FY 2020 Outpatient Prospective Payment System (OPPS) proposed rule is one that would alter the supervision standards applicable to hospital outpatient therapeutic services. See 84 Fed. Reg....more
8/29/2019
/ Centers for Medicare & Medicaid Services (CMS) ,
Conditions of Participation (CoP) ,
Critical Access Hospitals ,
Hospitals ,
Medicare ,
Outpatient Prospective Payment System (OPPS) ,
Outpatient Services ,
Physicians ,
Proposed Regulation ,
Proposed Rules ,
Public Comment ,
Rural Health Care Providers ,
Supervision ,
Therapeutic Services ,
Unduly Burdensome
CMS took another step in its campaign to impose "site neutrality" on hospital outpatient payments with its recently published final Medicare hospital Outpatient Prospective Payment System (OPPS) rule for CY 2019. The final...more
12/14/2018
/ Biologics ,
Centers for Medicare & Medicaid Services (CMS) ,
Emergency Rooms ,
HCPCS ,
Health Care Providers ,
Hospitals ,
Medicare ,
MedPAC ,
Off-Campus Departments ,
OPPS ,
Outpatient Services ,
Physician Medicare Reimbursements ,
Prescription Drugs ,
Provider Payments ,
Section 340B ,
Site-Neutral Exception
Is the Department of Health and Human Services (HHS or the government) required to engage in notice and comment rulemaking when it changes a requirement that has an important impact on hospitals' reimbursement? As we reported...more
10/11/2018
/ Administrative Procedure Act ,
Appeals ,
Azar v Allina Health Services ,
Centers for Medicare & Medicaid Services (CMS) ,
Certiorari ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
Health Care Providers ,
Hospitals ,
Interpretive Rule ,
Medicare ,
Medicare Part C ,
Notice and Comment ,
Petition for Writ of Certiorari ,
Physician Medicare Reimbursements ,
Provider Payments ,
Rulemaking Process ,
SCOTUS
CMS recently published its proposed Medicare outpatient prospective payment system (OPPS) rule for calendar year (CY) 2019. The rule contains a number of "site-neutral" proposals that, if adopted, will result in lower...more
8/8/2018
/ Bipartisan Budget Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Hospitals ,
Medicare ,
Medicare Payment Reform ,
Off-Campus Departments ,
OPPS ,
Outpatient Prospective Payment System (OPPS) ,
Provider Payments ,
Section 340B ,
Trump Administration
In Northeast Hosp. Corp. v Sebelius, 657 F.3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit upheld hospitals' challenge to CMS's disproportionate share hospital (DSH) calculation...more
7/16/2018
/ Administrative Appeals ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Inpatient Prospective Payment System (IPPS) ,
Judicial Review ,
Medicaid ,
Medicare ,
Provider Payments ,
Reviewability Determinations ,
Statutory Construction Test
On March 27, 2018, the United States Court of Appeals for the Fifth Circuit published an opinion that provides Family Rehabilitation, Inc. (Family Rehab) a second chance to postpone recoupment of about $7.6 million in...more
4/12/2018
/ Administrative Appeals ,
Administrative Backlogs ,
Administrative Law Judge (ALJ) ,
Appeals ,
Dismissals ,
Due Process ,
Exhaustion Doctrine ,
Health Care Providers ,
Judicial Review ,
Medicare ,
Overpayment ,
Preliminary Injunctions ,
Recoupment ,
Reversal ,
Social Security Act ,
Subject Matter Jurisdiction ,
TRO ,
Ultra Vires
On December 26, 2017, the United States Court of Appeals for the District of Columbia Circuit upheld the procedural validity of 2010 manual instructions setting out the criteria by which Medicare outlier payments might be...more
For much of the past decade, hospitals and CMS have battled over whether providers may claim, as Medicare reasonable costs, the full amount of provider tax assessments levied upon them by the states in which they operate. In...more
1/17/2018
/ Appeals ,
Arbitrary and Capricious ,
Centers for Medicare & Medicaid Services (CMS) ,
Health Care Providers ,
Hospitals ,
Medicaid ,
Medicare ,
Medicare Taxes ,
Physician Medicare Reimbursements ,
Provider Reimbursement Manual ,
Provider Reimbursement Review Board ,
Refunds ,
Reversal
Recent guidance from CMS suggests that some hospitals, and particularly specialty hospitals that provide mostly outpatient care, may soon find themselves the focus of surveyors' scrutiny. In early September, CMS issued...more
Hospitals affected by HHS's 2014 decision to include Medicare Part C enrollees as part of the Medicare fraction of the disproportionate share calculation obtained relief late last month when that position was voided by the...more
8/28/2017
/ Administrative Procedure Act ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Medicare ,
Medicare Part C ,
Notice and Comment ,
Provider Payments ,
Retroactive Application ,
Reversal
For the better part of a decade, hospitals and CMS have fought over the extent to which hospitals may claim as reasonable costs the provider tax assessments levied on them by the individual states in which they operate. In...more
In April 2015, CMS issued Ruling 1498-R2 addressing the calculation of the Medicare fraction of the disproportionate share hospital (DSH) adjustment for patient discharges prior to October 1, 2004. CMS has now issued...more
CMS recently published its final outpatient prospective payment system (OPPS) rule, which includes its new policies governing payment related to services furnished at off-campus provider-based departments (OPBDs). 81 Fed....more
On July 26, 2016, the United States Court of Appeals for the District of Columbia Circuit decided Fla. Health Sciences Ctr. v. Burwell. In that case, the Court analyzed a statutory bar against judicial review of estimates...more
10/5/2016
/ Administrative Procedure Act ,
Administrative Review ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Judicial Review ,
Medicaid ,
Medicare ,
Non-Appealable Decisions ,
Provider Payments ,
Reviewability Determinations
On July 29, 2016, CMS announced that it is lifting a temporary moratorium on Medicare Part B, Medicaid, and Children's Health Insurance Program (CHIP) emergency ambulance suppliers, but extending and expanding similar...more
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 25, 2016, entitled, Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and...more
8/10/2016
/ ACOs ,
Alternative Payment Models (APM) ,
Appeals ,
BPCI ,
Centers for Medicare & Medicaid Services (CMS) ,
Collaboration ,
Episode Payment Models (EPM) ,
Fraud and Abuse ,
Gainsharing ,
Hospitals ,
Incentive Compensation ,
Medicare ,
Medicare Access and CHIP Reauthorization (MACRA) ,
Medicare Shared Savings Program ,
MIPS ,
Physicians ,
Proposed Rules ,
Public Comment ,
Telehealth ,
Waivers
In a detailed opinion that likely constitutes the last word on the matter, the Eleventh Circuit recently held in Fla. Agency for Health Care Administration v. Bayou Shores SNF, LLC that bankruptcy courts lack jurisdiction...more
As we reported in a Payment Matters article last November 12, 2015, Section 603 of the Bipartisan Budget Act of 2015 changes the payment rules applicable to off-campus, provider-based locations that are new as of November 2,...more
On March 31, 2016, Judge Colleen Kollar-Kotelly of the United States District Court for the District of Columbia (the “D.C. District Court”) issued a highly anticipated memorandum opinion settling what will probably be the...more
As part of the Outpatient Prospective Payment System (OPPS) final rule published in the Federal Register on November 13, 2015, CMS made noteworthy changes to the Medicare cost report and appeal rules. See 80 Fed. Reg. 70298...more
In a decision handed down on August 7, 2015, the United States Court of Appeals for the District of Columbia Circuit upheld the denial of the providers' bad debt claims associated with dual eligible beneficiaries. Grossmont...more
9/5/2015
/ Appeals ,
Bad Debt ,
Centers for Medicare & Medicaid Services (CMS) ,
Co-Insurance Payments ,
Deductibles ,
Dual Beneficiaries ,
Filing Deadlines ,
Hospitals ,
Medi-Cal ,
Medicaid ,
Medicare ,
Provider Reimbursement Manual
As we reported in previous Payment Matters articles, the United States District Court for the District of Columbia has issued inconsistent opinions regarding Medicare's policy not to allow bad debt when that bad debt is still...more
On July 14, 2015, CMS released a proposed rule regarding a new, alternative payment model: the Comprehensive Care for Joint Replacement (CCJR) program. Modeled in large part on the Bundled Payments for Care Improvement (BPCI)...more