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Keeping you afloat amidst the rising sea of regulations

The Move to Value-Based Payment Continues: CMS Announces Initiative to Transform Primary Care Delivery and Payment

On April 11, 2016, the Centers for Medicare and Medicaid Services (CMS) announced its Comprehensive Primary Care Plus (CPC+) initiative. Part of CMS’ attempt to shift Medicare from its traditional fee-for-service model to a value-based care model, CPC+ is CMS’ largest attempt so far to transform the way primary care is provided and reimbursed.

CMS Announces Stepped-Up Provider and Supplier Enrollment Screening

The Centers for Medicare and Medicaid Services (CMS) intends to strengthen provider and supplier enrollment screening – meaning, scrutinize providers and suppliers more closely during enrollment – according to a February 22, 2016 post on its blog, The CMS Blog.

CMS’s Long-Awaited Final 60-Day Repayment Rule Provides Guidance and Eases Some Requirements for Health Care Providers and Suppliers

On Friday, February 12, 2016, the Centers for Medicare and Medicaid Services (CMS) released the long-awaited Final Rule and regulations,[1] providing much needed guidance to providers and suppliers on how to meet the Affordable Care Act’s (ACA’s) 60-day overpayment mandate.[2] Specifically, a provision enacted as part of the ACA in 2010 requires that all Medicare and Medicaid overpayments be reported and returned by the later of (i) 60 days after the date on which the overp

Another Reminder of All That Needs to Be Fixed in the Health Care System

I was amused after reading the California Court of Appeal opinion in the case of Unilab Corporation v. Angeles-IPA. The legal issues in the case are fairly straight forward and unremarkable. However, the court’s description of the facts of this case are of interest, as they reveal some of the complexity in the delivery of, and payment for, health care services. In this situation, testing by a commercial laboratory of specimens drawn at a physician’s office.

Yet Another Challenge to the Affordable Care Act: House of Representatives’ Constitutional Claim Allowed to Proceed

After already surviving two challenges that resulted in U.S. Supreme Court decisions that essentially preserved the law (National Federation of Independent Business v. Sebelius and King v. Burwell), the Affordable Care Act will face additional judicial scrutiny as a federal district court has denied the administration’s motion to dismiss the case brought by the House last year. (United States House of Representatives v.

First In Kind False Claims Act Settlement Based Upon Failure to Investigate and Return Overpayment

Earlier this week, BNA’s Health Care Daily Report picked up on the announcement of a settlement in two False Claims Act cases. (United States ex rel. Odumosu v. Pediatric Servs. of Am. Healthcare, N.D. Ga., No. 1:11-cv-1007; United States ex rel. McCray v. Pediatric Servs. of Am., S.D. Ga., No.

Midsummer Nightmare: Opinion in Continuum Health Partners Case Suggests We Can Identify the Unknown

On Monday, a federal district court judge in New York issued a ruling that, if adopted broadly, will have a significant – and potentially nightmarish – impact on any provider who receives an overpayment from Medicare or Medicaid. Kane v. Healthfirst, Inc. and U.S. v.

What the Obergefell v. Hodges Decision May Mean to the Health Care Industry

King v. Burwell understandably took the attention of the health care industry a couple of weeks ago when it upheld a key component of the Affordable Care Act. A day later, however, the Supreme Court released another decision that may have a more significant going-forward impact on the health care industry: the Obergefell decision, which declares that gay individuals have a right under the 14th Amendment and Equal Protection Clause of the U.S.

Subsidies Survive! Supreme Court Upholds ACA Tax Credits in King v. Burwell

In the long awaited decision in King v. Burwell, the Supreme Court ruled this morning in a 6-to-3 decision that the Affordable Care Act (ACA) permits tax credits for individuals who purchase their health insurance through a Federal health insurance marketplace (Federal Exchange), not just for individuals who purchase through State-operated marketplaces.

CMS Provides More Options for ACOs Looking to Share in Medicare Savings

On June 9, 2015, the Centers for Medicare and Medicaid Services (CMS) published a final rule in the Federal Register making changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs). These changes were intended to encourage increased participation by hospitals, rural health centers, federally qualified health centers, physicians, and other eligible health care providers in the Shared Savings Program and i