Category Archives: Medicare & Reimbursement

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DOJ and HHS Launch New False Claims Act Working Group to Target Healthcare Fraud

The U.S. Department of Health and Human Services (HHS) and the Department of Justice (DOJ) have jointly announced the launch of a reinvigorated DOJ-HHS False Claims Act Working Group aimed at enhancing interagency coordination around key fraud enforcement priorities in the healthcare space. This initiative underscores the federal government’s ongoing reliance on the False Claims … Continue Reading

New CMS Model Targets Inefficient Medicare Spending Through AI and Clinical Oversight

The Centers for Medicare & Medicaid Services (CMS) has launched the WISeR Model (Wasteful and Inappropriate Service Reduction) to modernize and streamline Medicare’s prior authorization process. By partnering with tech companies, CMS will test the use of modern tools, such as artificial intelligence, to reduce unnecessary or low-value services that drive up costs and pose … Continue Reading

DOJ Announces Largest Health Care Fraud Takedown in U.S. History

In the largest health care fraud takedown in U.S. history, the Justice Department announced charges against 324 individuals—including 96 licensed medical professionals—in connection with schemes involving over $14.6 billion in intended losses across 50 federal districts and 12 State Attorneys General Offices. The coordinated enforcement action led to the seizure of more than $245 million … Continue Reading

2025 Medicare Final Rule Highlights

Attorneys Mike Cassidy and Adam Appleberry co-authored an insightful article, 2025 Medicare Final Rule Highlights, featured in the December 2024 issue of the Allegheny County Medical Society (ACMS) Bulletin. The article explores the key updates to Medicare regulations and their implications for healthcare providers. Click here to access the ACMS Bulletin to read the full … Continue Reading

Medicare Telehealth Reimbursement Update

Our Introduction to Telehealth, Technology and Federal Enforcement chapter was published in the Thomson Reuters 2025 Health Law Handbook.  It reviewed a number of telehealth Medicare revisions, both permanent and temporary, enacted by a series of consolidated appropriation acts and physician fee schedule amendments arising out of the 2020 COVID pandemic. The temporary telehealth provisions … Continue Reading

Medicare Proposed 2025 Telehealth Changes

CMS proposed several telehealth changes in the 2025 Medicare Physician Fee Schedule Proposed Rule, issued July 10, 2024.  Interactive Telecommunication Beginning January 1, 2025, an interactive telecommunication system may include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home, if the distant site physician or practitioner is technically … Continue Reading

Penn State Health Agrees To Pay Over $11 Million Due To Violations Of Medicare Rules & Regulations

Penn State Health has agreed to pay $11,712,336 to settle allegations of civil liability from submitting improper claims to Medicare for Annual Wellness Visit services. DOJ Press Release Link Penn State Health has voluntarily disclosed that between December 2015 and November 2022 claims were submitted to Medicare for Annual Wellness Visit services that were not … Continue Reading

Medicare Physician Fee Schedule Reductions Partially Offset

The final “2023 Omnibus Bill” which is the spending bill passed by Congress and signed by President Biden at the end of 2022, provides partial relief from the scheduled Medicare Physician Fee Schedule Conversion Factor cuts. As previously reported, the changes to the Medicare Physician Schedule Conversion Factor would have reduced physician reimbursement by 4.5%. … Continue Reading

2022 Medicare Rules for Facility-Based Split/Shared Visits

There has been much discussion and controversy over the new CMS position on billing for split/shared services in facility settings. As originally proposed, and starting in January 2022, if the service was shared among providers (such as physicians and physician assistants), the provider who performed the substantive portion of the visit would be the provider … Continue Reading

“Stark” Rules: Navigating Physician Leases and Subleases

Under the Federal Ethics in Patient Referrals Act (more commonly known as “Stark”), if a physician[1] has a financial relationship with an entity, the physician may not refer patients to the entity for medical services payable by Medicare unless the financial relationship complies with the Stark safe harbors.  Thus, entities that lease or sublease space or … Continue Reading

CMS Policy Summary: 2022 Medicare Physician Fee Schedule, Telehealth Originating Site Facility Fee and Services List, and Physician Assistant Billing

In MLN Matters article MM 12159, CMS has published summaries of the following: Updates to payment policies and Medicare payment rates for services provided by physicians and non-physician practitioners (NPP) Updates to Medicare telehealth services and telehealth originating site facility fee payment amounts Billing for a physician assistant (PA) services  … Continue Reading

2021 Medicare Fee Schedule Conversion Factor Reduction Reversed

CY 2021 Physician Fee Schedule Update On December 27, 2020, the Consolidated Appropriations Act modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS): Provided a 3.75% increase in MPFS payments for CY 2021 Suspended the 2% payment adjustment (sequestration) through March 31, 2021 Reinstated the 1.0 floor on the work Geographic Practice Cost … Continue Reading
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