HHS has long admitted that the Anti-Kickback Statute (AKS) and the Stark law have not evolved to keep pace with the transition to value based care. In June of 2018, HHS issued an RFI seeking additional information and HHS also issued a release on December 12, 2018 seeking input on improving care coordination and reducing … Continue Reading
CMS published the 2015 Open Payment Data on June 30, 2015. This is the link to the notice and the CMS site: https://openpaymentsdata.cms.gov/ CMS has presented tables in its press release showing the highest paid specialties and highest paying companies. Over the last two years, Novartis has paid approximately $842 million to 344,000 recipients, which … Continue Reading
The Centers for Medicare & Medicaid Services (CMS) has finalized the 60-day overpayment rule. I have attached the article I prepared for ACMS Legal Bulletin here.… Continue Reading
CMS has issued the final regulations to implement that section of the Affordable Care Act amending the Social Security Act to provide that retention of identified overpayment could be a false claim and be subject to both the False Claims Act (FCA) and the Civil Money Penalty Act (CMP). ACA § 6402(a) established new Social … Continue Reading
In July 2015, CMS released proposals to provide several new Stark Law exceptions and to clarify issues regarding existing exceptions. The full text of these proposal and CMS comments and explanations is available at: https://www.federalregister.gov/articles/2015/07/15/2015-16875/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions http://www.gpo.gov/fdsys/pkg/FR-2015-07-15/pdf/2015-16875.pdf Perhaps the most noteworthy of the lesser proposals were clarifications that: “hold over arrangements” are permitted to satisfy the … Continue Reading
CMS issued a special edition MLN Matters meant to be effective August 1, 2015. The guidance reflects CMS instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations of certain claims. CMS acknowledges its concern that MACs and QICs were using their discretion to conduct … Continue Reading
CMS has acknowledged that arrangements among providers to satisfy the Stark exceptions need not be created in a single document. Although a single written document memorializing the key facts of an arrangement could provide the surest and most straightforward means of establishing compliance with the applicable exception, there is no requirement under the physician self-referral … Continue Reading
In July 2015, CMS released proposals to provide several new Stark Law exceptions and to clarify issues regarding existing exceptions. Over the next few days, I will post comment on what I consider the most significant new exceptions and clarifications. The full text of these proposal and CMS comments and explanations is available at: https://www.federalregister.gov/articles/2015/07/15/2015-16875/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions … Continue Reading
In July 2015, CMS released proposals to provide several new Stark Law exceptions and to clarify issues regarding existing exceptions. Over the next few days, I will post comments on what I consider the most significant new exceptions and clarifications. The full text of these proposals and CMS comments and explanations are available at: https://www.federalregister.gov/articles/2015/07/15/2015-16875/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions … Continue Reading
By now, everyone knows ICD-10 coding starts October 1, 2015. Starting October 1, 2015, Medicare claims with dates of service after October 1, 2015 will only be accepted if they contain a valid ICD-10 code. The Medicare claims system will be programmed not to accept ICT-9 codes after September 30, 2015. However, Medicare announced in … Continue Reading
The Centers for Medicare and Medicaid Services (CMS) released a proposed rule intended to make ACOs and Medicare Shared Savings Plans more practical and attractive to potential providers. The proposed rule was released on December 1, 2014, along with a CMS Fact Sheet. Longer Lead Time to Develop In order to provide more development time, … Continue Reading
On July 21, 2014, I posted the proposed Medicare Physician Fee Schedule, and described the intent by CMS to eliminate global surgery. On November 13, 2014, CMS issued the final 2015 Medicare Physician Fee Schedule, and CMS incorporated the changes regarding global surgery. Global Surgery There are three primary categories of global surgery packages that … Continue Reading
In the proposed 2015 Medicare Physician Fee Schedule, CMS is seeking comments regarding expanding coverage for secondary interpretation of diagnostic imaging. I’m enclosing pages 40370 and 40371 of the proposed Medicare Physician Fee Schedule. The enclosed material sites the Medicare Claims Processing Manual provisions which make is clear that a professional component interpretation service should … Continue Reading
In the recently proposed 2015 Physician Fee Schedule, CMS devoted significant resources to discussing potentially misvalued services, which I believe is code for places where CMS would like to reduce reimbursement. One of the areas is global surgery fees. CMS has concerns with the 10 and 90 day global surgery fees because these global packages … Continue Reading
CMS has taken a small step to implement President Obama’s executive order instructing federal agencies to eliminate regulations that obsolete or overly burdensome to business. On October 24, 2011 CMS published the final rule revising Ambulatory Surgery Center (ASC) conditions for coverage to allow patient rights information to be provided to the patient, the patient’s … Continue Reading
The final rule on Accountable Care Organizations (ACOs) has been released by CMS. The final rule implements section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in ACOs under the Medicare Shared Savings Program. An advance copy of the final rule may be … Continue Reading
In CMS Advisory Opinion AO-2011-01, CMS has issued a favorable advisory opinion allowing the physician recruitment arrangement with a hospital and a physician practice which imposes a restrictive covenant upon the recruited physician. Restrictive covenants and recruitment arrangements had initially been prohibited by the Stark Rules. However, bowing to industry comment, CMS amended the physician recruitment … Continue Reading
The Centers for Medicare and Medicaid Services (CMS) has issued new proposed fraud and abuse rules in accordance with requirements of the Affordable Care Act (ACA) — first known as the Patient Protection and Affordable Care Act (PPACA). Section 6501(a) of ACA added Social Security section 1866(j), and required CMS to establish screening procedures for … Continue Reading
The 2010 Medicare Physician Fee Schedule The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010. The Centers … Continue Reading
Today the Senate passed an amended version of H.R. 4851, the act to extend SGR relief ( Continuing Extension Act of 2010 ) by continuing 2009 rates. Since an earlier but different version has already passed the House, this version must be approved again. The AMA predicts action by the end of the week. Although … Continue Reading
In the proposed changes to the Hospital Outpatient Prospective Payment System, CMS is proposing to change the physician supervision requirements applicable to hospital outpatient services described in the 2009 Hospital Outpatient Prospective Payment System (OPPS) final rule. In the proposed rulemaking release, issued July 1, 2009, CMS indicates that physician supervision requirements requiring "direct supervision" will … Continue Reading
The Centers for Medicare & Medicaid Services (CMS) has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent … Continue Reading
