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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.



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.



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).



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.


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


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


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


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.



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.



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.




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.



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.



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).