what wE KNOW.

Our team regularly assists providers in making sense out of one of the most challenging areas of health care.


August 2019

updates:

2020 Medicare Physician Fee Schedule - Reimbursement and Payment Policy Proposals

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) released the FY 2020 Medicare Physician Fee Schedule (MPFS) proposed rule [CMS-1715-P] (Proposed Rule). A link to the full rule is available here. Stakeholder comments on the rule are due no later than 5:00 pm ET on Friday, September 27, 2019. Because CMS released the proposed 2020 MPFS Proposed Rule later than in prior years and must publish a final rule by early November 2019, many stakeholders plan to submit prior to the deadline in order to give the Agency time to duly consider their suggestions and concerns.

View the full update here.

CMS Takes Bold Action on Price Transparency & Physician Supervision in CY 2020 OPPS Proposed Rule

On July 29, 2019, the Centers for Medicare & Medicaid Services (“CMS”) released the CY 2020 Hospital Outpatient Prospective Payment Systems (“OPPS”) proposed rule [CMS-1717-P] (display copy available here). In addition to the customary payment adjustments, the highlights of this year’s proposed rule are two policies with significant implications: (1) a broad price transparency policy, requiring hospitals to publish extensive charge and payment rate information; and (2) a proposal to reduce the required level of physician supervision from direct to general for hospital outpatient therapeutic services in all hospitals. This alert will focus on these policies and also address a series of ancillary proposals appearing in the 800+ page display copy of the proposed rule. The rule will be published in the Federal Register on August 9, 2019.

CY 2020 OPPS Proposed Rule – HHS Seeks Comments on 340B Payment Reductions and Remedies

This past week, CMS confirmed it will continue the 2018 and 2019 underpayment policy for certain 340B covered entities unless the D.C. Court of Appeals upholds the lower court’s ruling that it is unlawful. In that case, CMS signaled its intent to implement the highest permissible payment reduction, which it appears to interpret as 3%. CMS also signaled its intent to use the Administrative Procedure Act (APA) to delay any corrections to the underpayment until at least CY 2021, depending on when the D.C. Court of Appeals will issue its decision.

New Settlement Program for Medicare Overpayments

Medicare providers who have overpayments with pending requests for Administrative Law Judge (ALJ) hearings filed on or before March 31, 2019 may now take advantage of the renewed Settlement Conference Facilitation (SCF) program. This program allows the providers to meet with CMS representatives to discuss the possibility of a mutually agreeable resolution of the issues now rather than having to wait for months or even years longer to have their cases heard by a judge. Moreover, this is an opportunity for providers who have already re-paid most or all of their overpayment to begin to recover some of those monies. This is the first renewal of the program since a similar one was opened to parties with hearing requests pending prior to November 2017.


JUNE 2019

updates:

Reimbursement and Payor Dispute Update

Polsinelli is pleased to share the Health Care Reimbursement and Payor Dispute Update. This newsletter is a designated source of news, information and guidance on the constantly evolving reimbursement industry.

View the full newsletter here.


MAY 2019

updates:

Space Sharing Re-Boot: CMS Offers a New Approach in the State Operations Manual

On May 3, 2019, CMS published draft guidance regarding space sharing between co-located hospitals and hospitals co-located with other health care entities. This new guidance, published as an addition to Appendix A of the State Operations Manual (“SOM”), offers providers an opportunity to comment by July 2, 2019. Comments should be directed to HospitalSCG@cms.hhs.gov. CMS expects to publish final space sharing guidance following this comment period.

340B In The Spotlight – Key Program Developments

In this issue, Polsinelli’s 340B and Reimbursement teams provide an update on the most recent developments in the ongoing 340B /Part B Payment litigation and also highlight recent Government Accountability Office (“GAO”) interest in covered entities duplicate discount prevention efforts.


MARCH 2019

updates:

340B In The Spotlight – Key Program Developments

Polsinelli’s 340B and Reimbursement teams continue to closely monitor several key developments impacting 340B covered entities. There has been a flurry of federal and state developments in the past few weeks that may have significant implications on covered entities.


FEBRUARY 2019

updates:

Reimbursement and Payor Dispute Update

Polsinelli is pleased to share the Reimbursement and Payor Dispute Update. This newsletter is a designated source of news, information and guidance on the constantly evolving reimbursement industry.

View the full newsletter here.


JANUARY 2019

updates:

8th Circuit Ruling Impacting Commercial Payer Practices

After over a year of waiting, The Eight Circuit Court of Appeals aligns itself with the Department of Labor in determining that the practice of Cross-Plan Offsetting orchestrated by many commercial health insurance companies, and in this case United Healthcare, to recover erroneously overpaid claims from out-of-network health care providers is not only a violation of the terms of a self-funded benefit plan, but may also trigger additional liabilities for commercial health insurers and plan sponsors and administrators of self-funded benefit plans under ERISA.

 

The Path Forward - Big Decisions Ahead for ACOs under MSSP Final Rule

The December 21, 2018 “Pathways to Success” final rule governing Accountable Care Organizations participating in the Medicare Shared Savings Program (MSSP) will require expedited migration to financial risk arrangements.

 

Federal Judge Overturns Part B Payment Cuts to the 340B Drug Discount Program

A federal district court granted a permanent injunction against the Medicare Part B 2018 Outpatient Prospective Payment System (“OPPS”) payment cuts for separately payable, non-pass through drugs purchased through the 340B Drug Discount Program.


DECEMBER 2018

updates:

CMS Makes Changes to MSSP in 2019 Physician Fee Schedule

In the 2019 Medicare Physician Fee Schedule (MPFS) final rule published on November 23, CMS published new policies for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP).


NOVEMBER 2018

updates:

The Medicare Physician Fee Schedule for 2019

On November 1, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released an advanced copy of the final rule announcing policies and payment levels for the Medicare Physician Fee Schedule for 2019, implementing policy changes to the Quality Payment Program (“QPP”), and announcing other miscellaneous payment policies for Medicare Part B items and services.


AUGUST 2018

Speaking Announcements/Presentations:

Polsinelli Shareholder Cybil G. Roehrenbeck to Present at Center for Rural Health Annual Meeting

Polsinelli is proud to announce that Shareholder Cybil G. Roehrenbeck is a featured presenter at the 2018 Georgia Hospital Association's Center for Rural Health Annual Meeting. The conference schedule features abundant educational and networking opportunities with experienced professionals in the health care industry.


JULY 2018

updates:

CMS Targets Off-Campus Provider-Based Departments in 2019 OPPS Proposed Rule

On Wednesday July 25, 2018, the Centers for Medicare and Medicaid Services (CMS) released an advance copy of the CY 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS) proposed rule. 

 

Be Prepared: Provider-Based Mid-Build Audits Are Here

Hospitals with off-campus provider-based departments (“PBDs”) under construction (or “mid-build”) at the time of the Bipartisan Budget Act of 2015 – which limited Medicare payment to off-campus provider-based departments that were not operational prior to November 2, 2015– have been waiting years for Medicare to confirm the provider-based status of these locations.


APRIL 2018

updates:

Fifth Circuit Grants Health Care Providers Medicare Appeals Backlog Remedy

A recent ruling allows health care providers to seek relief from federal courts if the delay caused by the Medicare appeals backlog is likely to cause the provider irreparable injury.

 

Speaking Announcements/Presentations:

Polsinelli's Burris, Niecko-Najjum, Peters, and Vasquez to Present at HCCA Compliance Institute

Polsinelli is proud to announce that Shareholders R. Ross Burris, III,  Iliana L. Peters, Kyle A. Vasquez, and Associate Lidia M. Niecko-Najjum are featured presenters at the 2018 Compliance Institute, hosted by the Health Care Compliance Association.


MARCH 2018

updates:

Continuing Resolution Creates Significant Changes to Medicare and Medicaid Policies

The Bipartisan Budget Act of 2018, commonly referred to as the “Continuing Resolution,” was recently signed into law, creating a short-term fix to funding the federal government for six weeks while also raising the debt ceiling for one year and increasing spending limits for two years.


JANUARY 2018

updates:

Gainsharing Guidance: Clarification on Cost-Savings Arrangements Between Hospitals and Physicians

The Office of Inspector General of the U.S. Department of Health and Human Services (OIG) recently posted its first advisory opinion interpreting a gainsharing arrangement – that is, a financial relationship under which providers share in cost-savings – since passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

 

Six Things to Know on CMS's Guidance Addressing the Low Volume Medicare Appeal Settlement

The Centers for Medicare and Medicaid Services (“CMS”) recently issued guidance that starting Feb. 5, 2018, CMS will begin the process for the Low Volume Appeal (“LVA”) settlement option that CMS had announced on Nov. 3.


NOVEMBER 2017

updates:

Year 2 in the QPP: A Regulatory Update

On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Quality Payment Program (QPP) Final Rule. The Final Rule contains notable changes that may affect smaller practices participating in the Merit-based Incentive Payment System (MIPS) and clinicians’ strategic participation in Alternative Payment Models (APMs).

 

Newly-Announced 340B Payment Rule Presents Financial & Operational Challenges to All Covered Entities

In its 2018 Outpatient Prospective Payment System final rule (Final Rule) issued Nov. 1, Centers for Medicare and Medicaid Services (CMS) implemented a significant Medicare Part B payment reduction for separately payable, non-pass-through drugs provided in the hospital outpatient setting. CMS also finalized several new modifiers that will present significant operational challenges, given a very short turnaround time to implement.

 

Publications:

Medicare Settlement Plan Could Relieve Appeal Backlog

A pair of initiatives announced recently by the Centers for Medicare & Medicaid Services could allow the agency to resolve a portion of its gargantuan Medicare administrative appeals backlog.


OCTOBER 2017

updates:

The More Things Change, the More They Stay the Same – CMS’ Guidance on Co-Located Hospitals and the Removal of Certain Hospital Within Hospital Requirements

HwHs are hospitals excluded from the inpatient prospective payment system (“IPPS”), such as psychiatric, long-term care, children’s and cancer hospitals, but are located in the same building or on the same campus as another hospital (the “host hospital”).

 

Speaking Announcement/Presentation:

501 Medicare Enrollment: Appeals, Compliance, and Collateral Consequences Under CMS’s Expanded Revocation Authority

Polsinelli is proud to announce that Shareholder R. Ross Burris, III will present at the Healthcare Enforcement Compliance Institute, hosted by Health Care Compliance Association.


APRIL 2017

Speaking Announcements/Presentations:

Jeremy Burnette and Anthony Choe Present "Out-of-Network Reimbursement"

Polsinelli is proud to announce that Shareholder Jeremy Burnette and Counsel Anthony Choe will be presenting at the 2017 Emergency Department Practice Management Association (EDPMA) Solutions Summit in San Diego.


FEBRUARY 2017

updates:

Feb. 13 Deadline Looms for Provider-Based Departments Seeking Mid-Build Exception

A new section of the 21st Century Cures Act provides much-needed relief for hospitals with an off-campus provider-based department (PBD) that was mid-build or under development as of November 2, 2015 (the Mid-Build Exception).