Bill of Health

MARCH 24, 2023

The selections feature topics ranging from an analysis of the approval and marketing of biosimilars with a skinny label and their associated Medicare savings, to a discussion of the Philips Respironics recall and the need for reforms to U.S. Characteristics of Prior Authorization Policies for New Drugs in Medicare Part D. 2023 Feb 23.

Medicare 148

Medicare Medicare Medicaid Medicaid 148

Healthcare Law Blog

SEPTEMBER 28, 2023

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. As we predicted in February , this Final Rule is now being challenged in court.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Kaiser Health News

FEBRUARY 8, 2022

The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The total amount of the penalties is determined by how much each hospital bills Medicare.

Medicare 127

Medicare Medicare Hospitals COVID-19 127

Healthcare Compliance Blog

APRIL 14, 2022

The Office of Inspector General (OIG) released their findings of an audit they conducted to determine if hospital admissions of Indiana skilled nursing facility (SNF) residents who are enrolled in both Medicare and Medicaid (dually eligible beneficiaries) were potentially avoidable, and if level-of-care requirements for Medicare were met.

Medicare 59

Medicare Medicare Overpayments Overpayment 59

Bill of Health

OCTOBER 17, 2024

SB 1223 amended the California Consumer Privacy Act of 2018 to include neural data as sensitive personal information, whose collection and use companies can be directed to limit. AB 3030 requires that health care providers disclose when they have used generative AI to create communications with patients.

Medicare 150

Medicare Medicare Health Insurance Licensing 150

Healthcare Law Blog

MAY 16, 2022

More than 13 million people were enrolled in Medi-Cal in California in September 2021, making it the largest Medicaid program in the nation. In 2018, DHCS also launched the HHP pilot. In 2015, DHCS launched the WPC Pilots as part of its Medi-Cal 2020 Section 1115 Demonstration.

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Medicaid Medicaid Nurses Health Care Access 59

Health Care Law Brief

APRIL 3, 2023

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ( Rate Announcement ). 1395w-23): Medicare Advantage Organizations (MAOs) are paid a base rate by CMS. Risk Adjustment.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Healthcare Law Blog

MAY 5, 2022

Department of Health and Human Services Office of Inspector (“OIG”) released a report that studied prior authorization denials and payment denials by Medicare Advantage Organizations (“MAOs”) (the “Report”). Thirteen percent of denied prior authorization requests met Medicare coverage rules. The OIG Report. additional test results).

Medicare 52

Medicare Medicare Licensing Health Insurance 52

The Health Law Firm

OCTOBER 31, 2019

billion worth of false Medicare and Medicaid claims between July 2018 and January 2019. According to prosecutors, the doctor allegedly authorized genetic testing for patients he never met, in a state where he’s not licensed to practice medicine. The vast fraud scheme totaled $2.1 This appears to be a new national record.

Fraud 40

Fraud Medicare Medicare Doctors 40

Health Care Law Brief

APRIL 12, 2023

On April 5, the Centers for Medicare & Medicaid Services (“CMS”) released the 2024 Medicare Advantage and Prescription Drug Benefit Programs Final Rule (“Final Rule”), which will be codified at 42 C.F.R. The SRFs include low-income subsidy, dual eligibility (meaning eligible for Medicare and Medicaid) and disability.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

CMS.gov

NOVEMBER 16, 2018

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Fri, 11/16/2018 - 18:46. Administrator, Centers for Medicare & Medicaid Services. Most notably: The 2018 Medicare-FFS improper payment rate decreased from 9.51 percent in 2018. percent in 2018. percent in 2018.

Medicare 20

Medicare Medicare Overpayments Overpayment 20

Med-Net Compliance

JULY 20, 2022

A federal jury convicted a New York ENT doctor for defrauding Medicare and Medicaid by causing the submission of false and fraudulent claims for surgical procedures that were not performed. Medicare and Medicaid data demonstrated that he was identified as an outlier and the highest biller for this procedure in New York State.

Fraud 59

Fraud Doctors Medicare Medicare 59

AIHC

JANUARY 28, 2022

For more information on filing compliance cost reports, attend the Medicare Cost Report Camp in March 2022 presented by KraftCPAs and sponsored by the American Institute of Healthcare Compliance. This is calculated based on the hospital’s relative share of uncompensated care nationally. This is known as the hospital “market basket.”

Medicare 52

Medicare Medicare Hospitals Payment Systems 52

Healthcare Law Blog

JANUARY 25, 2023

Introduction: Defining Interprofessional Consultation In a January 5, 2023, letter to state health officials, the Centers for Medicare & Medicaid Services (“CMS”) clarified a Medicaid and Children’s Health Insurance Program (“CHIP”) policy on the coverage and payment of interprofessional consultations (the “Guidance”).

Medicaid 52

Medicaid Medicaid Medicare Medicare 52

Innovaare Compliance

JANUARY 19, 2021

It has become evident by changes to the Centers for Medicare & Medicaid Services (CMS) Star Rating formulas over the past several years—and especially with changes implemented for the 2021 Plan Year—that member experience and medication adherence is of utmost importance to the CMS. Medicare Star Ratings 2021 Changes.

Medicare 52

Medicare Medicare COVID-19 Compliance 52

The Health Law Firm

SEPTEMBER 24, 2018

Board Certified by The Florida Bar in Health Law On June 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued further guidance for reporting and reviewing final adverse legal actions (ALAs) in provider enrollment applications. Indest III, J.D., Section 15.5.3 Section 15.5.3 New Language Basics.

Medicare 40

Medicare Medicare Medicaid Medicaid 40

HIT Consultant

NOVEMBER 2, 2023

This partnership is a major development in the healthcare industry, representing the largest VBC provider deal since 2018. Initially, NS-EEH and Lumeris will focus on the opportunity to participate in the Centers for Medicare & Medicaid Services’ (CMS) ACO Realizing Equity, Access, and Community Health (ACO REACH) model.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

HealthStream

DECEMBER 19, 2019

Leaders are looking to optimize software solutions which provide methods to improve efficient communication and required payer ongoing verifications, as well as integration with the Council for Accountable Quality Healthcare (CAQH), State Medicaid, and Medicare enrollment.

Medicaid 40

Medicaid Medicaid Medicare Medicare 40

The Health Law Firm

OCTOBER 3, 2019

billion worth of false Medicare and Medicaid claims between July 2018 and January 2019. According to prosecutors, the doctor allegedly authorized genetic testing for patients he never met, in a state where he’s not licensed to practice. The vast fraud scheme totaled $2.1 Fraudulent Orders for Genetic Testing.

Fraud 40

Fraud Doctors Medicare Medicare 40

HIT Consultant

JUNE 12, 2024

Additionally, the Centers for Disease Control and Prevention reported a 39% increase in SUD cases in emergency departments (ED) from 2018 to 2021, exacerbating issues of overcrowding and overspending. Department of Health and Human Services revealed that in 2022, 17% of people aged 12 or older reported a substance use disorder (SUD).

Medicaid 96

Medicaid Medicaid Medicare Medicare 96

Healthcare Compliance Blog

JANUARY 14, 2022

million to settle allegations that the company sold custom fabricated shoe inserts to Medicare recipients that did not meet Medicare standards. Custom shoe inserts for diabetic patients can be covered by Medicare and Medicaid. A Florida based diabetic shoe company has agreed to pay over $5.5

Medicare 59

Medicare Medicare Medicaid Medicaid 59

The Health Law Firm

AUGUST 10, 2018

Board Certified by The Florida Bar in Health Law On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update payment policies, payment rates, and quality provisions for services rendered under the Medicare Physician Fee Schedule (PFS). Indest III, J.D.,

Medicare 40

Medicare Medicare Medicaid Medicaid 40

Healthcare Law Blog

NOVEMBER 2, 2023

According to the Congressional Research Service, which analyzed data from the Centers for Medicare & Medicaid Services (“CMS”) National Health Expenditure Accounts (“NHEA”) on the personal health expenditures for LTSS by payer, in 2021, an estimated $467.4 billion was spent on LTSS. This represents 13.2% of LTSS spending. [5]

Nursing Homes 52

Nursing Homes Medicaid Medicaid Medicare 52

Healthcare Law Blog

DECEMBER 27, 2022

The Centers for Medicare and Medicaid Services (“CMS”) has issued a proposed rule which would amend the existing regulations for reporting and returning identified overpayments (the “Proposed Rule”). 2018), rev’d in part on other grounds sub nom. UnitedHealthcare challenged the current Overpayment Rule in litigation. [1]

Overpayments 98

Overpayments Overpayment Medicare Medicare 98

Natalia Mazina

FEBRUARY 22, 2024

DIR fees were implemented with the creation of the Part D program through the passage of the Medicare Modernization Act of 2003. 2 As of 2018, DIR fees have increased to over six percent of the overall Medicare drug sales. There are three coverage phases in a Medicare recipient’s drug design.

Medicare 137

Medicare Medicare Patient Advocacy Medicaid 137

Med-Net Compliance

JUNE 15, 2022

California Attorney General Rob Bonta announced a settlement against a Southern California doctor for submitting false claims to Medicare and Medi-Cal between the years of 2011 and 2018 for drugs, procedures, services, and tests that were never administered to patients. two whistleblowers were the doctor’s former?medical

Fraud 59

Fraud Doctors Elder Abuse Medicare 59

HIT Consultant

JUNE 25, 2024

Researchers analyzed data from over 22,000 patients with newly diagnosed HCC between 2015 and 2018. The registry offers a de-identified dataset encompassing Medicare, Medicaid, commercially insured, and Medicare Advantage patients.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Healthcare IT Today

AUGUST 14, 2024

The Centers for Medicare and Medicaid Services reported more than 45% of provider office locations listed in online directories contained at least one error. A study ( “What Physicians are Saying About Directories” American Medical Association, 2018. However, much of this provider data has a short shelf life.

Fraud 71

Fraud Hospitals Medicaid Medicaid 71

CMS.gov

NOVEMBER 16, 2018

Washington Managed Fee-for-Service Demonstration: 2015 and 2016 Medicare Actuarial Savings Report. Fri, 11/16/2018 - 18:51. Director, Medicare-Medicaid Coordination Office, Topic. Medicare Parts A & B. Washington Managed Fee-for-Service Demonstration: 2015 and 2016 Medicare Actuarial Savings Report.

Medicare 35

Medicare Medicare Medicaid Medicaid 35

HIT Consultant

APRIL 3, 2023

Progress toward VBC adoption hasn’t achieved its potential yet, hovering around 60% of all payment models from 2018 to 2021, with the remaining 40% comprised of traditional fee for service (FFS).

Medicaid 96

Medicaid Medicaid Medicare Medicare 96

Innovaare Compliance

JUNE 21, 2023

The Inflation Reduction Act of 2022 has wide-ranging impact on payments for drugs used by Medicare beneficiaries, whether they are administered in the provider’s office (Part B) or used in the ambulatory setting (Part D). Part B drugs have had the fastest spending growth for drugs for Medicare. percent annually.

US Department of Health and Human Services 52

US Department of Health and Human Services Medicare Medicare Medicaid 52

HIT Consultant

MARCH 30, 2023

The platform allows connectivity to the key services providers require to address patient needs including prescription delivery, stress-free rides, and soon, the delivery of healthy food and over-the-counter medicine for those who need it most—including Medicare Advantage and Medicaid beneficiaries.

Medicaid 92

Medicaid Medicaid Medicare Medicare 92

C&M Health Law

DECEMBER 21, 2022

HHS also adopted the NCPDP Batch Standard Medicaid Subrogation Implementation Guide, Version 3, Release 0 (Version 3.0) Since 2018, NCHVS has issued recommendations to adopt the following standards: NCPDP Telecommunications Standard Implementation Guide Version F6 (to replace Version D.0);

HIPAA 52

HIPAA Medicaid Medicaid Health Insurance 52

Innovaare Compliance

MARCH 4, 2024

Until the enactment of the Medicare Modernization Act (MMA) in 2006 [1] , the Centers for Medicare & Medicaid Services does not cover most outpatient prescription drugs under Part B (“Part B drugs”). However, some drugs self-administered by Medicare beneficiaries at home are Part B eligible.

Medicare 52

Medicare Medicare Nurses Medicaid 52

Provider Trust

JULY 26, 2023

The Centers for Medicare and Medicaid Services (CMS) conducted multiple reviews of Medicaid Advantage provider directories between February 2016 and July 2018. Their report from the third round of reviews found that of the 108 providers selected from 52 Medicare Advantage Organizations (MAO) directories, 48.7%

Medicaid 52

Medicaid Medicaid Compliance Medicare 52

Hall Render

JULY 7, 2023

The Centers for Medicare & Medicaid Services (“CMS”) just released its Proposed Rule for repaying hospitals that were affected by the 340B OPPS payment cuts from 2018 through 2022. CMS has proposed that 340B hospitals will receive a one-time lump sum payment at the end of 2023 or beginning of 2024.

Hospitals 40

Hospitals Medicaid Medicaid Medicare 40

Bill of Health

MARCH 25, 2022

Medicaid Expenditures and Estimated Rebates on Line Extension Drugs, 2010-2018. New EU regulation on health technology assessment of cancer medicines. Lancet Oncol. 2022 Feb;23(2):e58. PMID: 35114127. Hwang TJ, Feng J, Maini L, Kesselheim AS. J Gen Intern Med. 2022 Feb 22. Epub ahead of print. PMID: 35194743.

FDA 209

FDA COVID-19 Medicaid Medicaid 209