Showing 73 posts in Medicare/Medicaid.
Is Losing Money by Employing Physicians a Stark Violation?
Modern Health Care has reported that hospitals often lose approximately $176,000 a year per each employed physician.
While this initially seems like a surprising statistic, it is understandable that hospitals lose money when they employ physicians. Physicians in private practice often pay their staff less than comparable hospital employees. When a hospital buys a physician’s practice, the benefit costs typically increase if the staff receives the hospital’s fringe benefit package. Moreover, hospital overhead is typically higher than a private physician practice with regard to HR costs and other support services.
Many systems claim that the only way to manage the health of a given population (which is what ACO and other similar payment structures are requiring) is to be fully integrated with employed physicians, so covering the losses incurred by employing physicians is the necessary cost of preparing for the new paradigm. The ugly, and legally problematic, truth is that most health systems look beyond the income generated by physicians for treating patients but also at income from physician ancillary referrals to justify the economic losses caused by acquiring physician practices. This raises concerns under the Stark law. Read More ›
Categories: Billing/Payment, Compliance, Hospitals, Medicare/Medicaid, Physicians
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CMS Issues Final Rule on Reporting and Returning Overpayments
On February 11, 2016, the Centers for Medicare & Medicaid Services (“CMS”) issued its long-awaited Final Rule on Reporting and Returning of Overpayments (the “Final Rule”). The Final Rule, which will become effective on March 14, 2016, implements section 1128J(d) of the Affordable Care Act (“ACA”). This Section of the ACA requires that Medicare providers report and return Medicare overpayments by the later of (A) the date that is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable (the “60-day rule”). According to CMS, the purpose of the Final Rule is to provide “needed clarity and consistency in the reporting and returning of self-identified overpayments.”
CMS issued a Proposed Rule on Reporting and Returning of Overpayments (the “Proposed Rule”) on February 16, 2012. The Final Rule includes some important changes to the provisions of the Proposed Rule. A summary of the major provisions of the Final Rule appears below. Read More ›
Categories: Billing/Payment, Health Care Reform, Medicare/Medicaid, News & Events
CMS Releases Draft Plan to Support Transition to Value-Based Payment System
As part of the continuing transition toward a physician payment system based more on quality than quantity, the Centers for Medicare & Medicaid Services (“CMS”) recently released a draft Quality Measure Development Plan (the “Plan”). The Plan is authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”), which mandated that CMS post a draft plan for the development of quality measures by January 1, 2016. The Plan explains how CMS will support the transition to the new Merit-Based Incentive Payment System (“MIPS”) and Alternative Payment Models (“APMs”). Read More ›
Categories: Medicare/Medicaid
CMS Issues Final Home Health Payment Rules for 2016
On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued the final home health prospective payment system (PPS) rule for calendar year (CY) 2016. CMS projects that the impact of the final rule will result in a 1.4 percent (or $260 million) reduction in Medicare payments to home health agencies (HHAs) from 2015 payment levels. Read More ›
Categories: Billing/Payment, Medicare/Medicaid
Department of Justice Enters Into Record-Breaking Stark Law Settlement
The U.S. Department of Justice (DOJ), and a handful of states, recently reached a settlement agreement with Adventist Health System (Adventist), resolving Stark Law issues, as well as allegations in two separate qui tam actions that included false claims. Generally speaking, the Stark Law limits physician referrals of designated health services or “DHS” for Medicare and Medicaid patients in instances where the physician - or an immediate family member of the physician - has a financial relationship with the DHS entity. Read More ›
Categories: Billing/Payment, Medicare/Medicaid, News & Events, Physicians
Quality vs. Quantity: Accountable Care Organization Results Keep Coming, as Does Some Criticism
One of the primary ways that the Affordable Care Act seeks to reduce health care costs is through the formation of Accountable Care Organizations (ACO). ACOs are still a relatively new concept in the healthcare world, as they emerged in 2011 as a result of an initiative by the Centers for Medicare & Medicaid Services (CMS).
ACOs are generally groups of doctors, hospitals, and other health care providers, who voluntarily join forces for the purpose of providing coordinated care to Medicare patients (see other Foster Swift articles on ACOs). ACOs were established as a means of coordinating care in order to ensure that patients, especially the chronically ill, receive effective care while avoiding unnecessary duplication of services and preventing medical errors. ACOs that achieve cost saving from providing timely and accurate care that meet quality benchmarks share in Medicare savings. In short, ACOs are intended to encourage quality of care, not quantity of care, and ACOs that deliver care more efficiently are eligible for bonuses. Read More ›
Categories: Accountable Care Organizations, Health Care Reform, Medicare/Medicaid, News & Events, Providers
CMS Issues Final Rules for Fiscal Year 2016 Provider Payments
On July 31, 2015, the Centers for Medicare & Medicaid Services (“CMS”) issued final Medicare payment rules for federal fiscal year 2016 (the “Rules”). The Rules affect hospitals, hospices, psychiatric facilities, and rehabilitation facilities. Read More ›
Categories: Billing/Payment, Medicare/Medicaid, News & Events, Providers
Government Intervenes in Affordable Care Act 60 day Rule Violation Allegation
In a first-of-its-kind and closely followed case, a U.S. district court denied a New York health system's (Healthfirst’s) motion to dismiss the U.S. government's and State of New York's complaints in intervention under the federal False Claims Act (FCA) and New York state counterpart. This case represents the first time that the government has intervened in an FCA case based upon an allegation that a party violated the "60 day rule." The 60 day rule came into existence with the passage of the Affordable Care Act (ACA) in 2010 and subjects parties to FCA liability for failing to report and refund an overpayment within 60 days of identification, even if the defendant received the payment through no fault of its own.
The case, Kane ex rel. United States et al. v. Healthfirst et al., involves three hospitals that were part of the Healthfirst health system network and provided care to patients that were part of Healthfirst's Medicaid managed care plan. Healthfirst received payments from the New York State Department of Health (DOH) in return for services provided to Medicaid eligible enrollees.
The government's allegations stem from overpayments to Healthfirst as a result of a software glitch. Healthfirst was first questioned about the possible overpayments by the New York State Comptroller's office in 2010. The health system tasked Kane, an employee and the eventual whistleblower in the case, to look into the payments. Five months later Kane emailed Healthfirst management a spreadsheet listing over 900 claims totaling more than $1 million that contained an erroneous billing code that may have led to the overpayments. Read More ›
Categories: Billing/Payment, Fraud & Abuse, Health Care Reform, Hospitals, Medicare/Medicaid, News & Events, Providers
CMS Issues Proposed Rules for Medicaid Managed Care
Last month, for the first time in over a decade, the Centers for Medicare & Medicaid Services (CMS) published proposed revisions to the Medicaid managed care regulations. According to CMS, the proposed rule aims to reflect the changes in delivery systems, strengthen the system’s ability to serve diverse populations, and promote greater alignment of Medicaid managed care policies with those of other payers. A summary of the key provisions of the proposed rule appears below. Read More ›
Categories: Billing/Payment, Medicare/Medicaid, News & Events
CMS Proposes Rule to Update Wage Index and Payment Rate for the Medicare Hospice Benefit
On April 30, 2015, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule that would update fiscal year (“FY”) 2016 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries (the “Proposed Rule”). CMS estimates that the Proposed Rule would result in a 1.3 percent ($200 million) increase in hospice payments for FY 2016. The highlights of the Proposed Rule are summarized below. Read More ›
Categories: Billing/Payment, Medicare/Medicaid, News & Events
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Best Lawyers® 2021
Congratulations to the attorneys of the Health Care practice group at Foster Swift Collins & Smith, PC for their inclusion in the Best Lawyers in America 2021 edition. Firm-wide, 44 lawyers were listed. Best Lawyers lists are compiled based on an exhaustive peer-review evaluation and as lawyers are not required or allowed to pay a fee to be listed; inclusion in Best Lawyers is considered a singular honor. Health Care practice group members listed in Best Lawyers are as follows:
- Jennifer B. Van Regenmorter, Holland
To see the full list of Foster Swift attorneys listed in Best Lawyers 2021, click here.