what wE KNOW.
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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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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).
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.
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).
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.
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.
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”).
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.
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.
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).