On January 17, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule regarding interoperability and prior authorization (the “Rule”). CMS-0057-F. The Rule’s goals, according to CMS, are to facilitate the electronic exchange of health-care data, improve and expedite prior authorization processes, and reduce related burdens for payers, healthcare providers, and patients, … Continue Reading
In August, the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) introduced a new “Strategic Plan for Oversight of Managed Care for Medicare and Medicaid” (the “Strategic Plan”). The introduction of the Strategic Plan is in response to the continued growth of managed care in government sponsored health … Continue Reading
On May 10, 2023, the Center for Medicare & Medicare Services (“CMS”) issued guidance to clarify the definition of “marketing” for Medicare Advantage Plans (“MA Plans”) and Prescription Drug Plans (“PDPs”).[1] The new definition expands “marketing” to include activities intended to draw a consumer’s attention to an MA Plan or PDP, influence a consumer’s decision-making … Continue Reading
In October 2022, the Centers for Medicare and Medicaid Services (“CMS”) requested information from the public regarding its proposal to establish a National Directory of Healthcare Providers and Services (“NDH”). This proposal was a response to recent CMS data showing that nearly half of Medicare Advantage plan directories were inaccurate, despite CMS’s quarterly reporting requirements. … Continue Reading
In a recent decision, the United States Court of Appeals for the Ninth Circuit affirmed dismissal of a medical provider’s complaint against a Medicare Advantage Organization (“MAO”) because the provider failed to exhaust all administrative remedies under the Medicare Act. Glob. Rescue Jets, LLC v. Kaiser Found. Health Plan, Inc., 30 F.4th 905 (9th Cir. … Continue Reading
Coronavirus disease 2019 (COVID-19) is a rapidly spreading global health problem. Over the past week, state and federal regulators have issued guidance and imposed requirements on health insurance companies and managed care plans (health insurers) to broaden and tailor coverage to COVID-19. This alert serves as a guide to assist our clients with understanding the … Continue Reading
In MSPA Claims 1, LLC v. Kingsway Amigo Ins. Co., the 11th Circuit was tasked with answering the question of whether 42 U.S.C. § 1395y(b)(2)(B)(vi) imposes a timeliness requirement with which the government or a private entity must comply as a prerequisite to filing suit to seek reimbursement for payments that it made on behalf … Continue Reading
CMS said it plans to audit risk-adjustment payments that Medicare Advantage (MA) plans received based on having identified additional diagnoses in beneficiary medical chart reviews. CMS’s action was spurred by a recent report from the HHS Office of Inspector General (OIG) entitled, “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns.” (Click here … Continue Reading
On Friday, November 30, 2018, the US Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (Proposed Rule) to revise Medicare Part D (Part D) and Medicare Advantage (MA) regulations to promote health plan negotiation of lower drug prices and to reduce out-of-pocket spending for enrollees. The Proposed Rule contains four areas of … Continue Reading
On October 26, 2018, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule that will, among others initiatives, allow CMS to recover higher dollar amounts of improper payments made to Medicare Advantage Organizations. Improper payments are identified through Risk Adjustment Data Validation (“RADV”) audits, which are audits conducted to determine whether the … Continue Reading
On Wednesday, May 16, the House Ways and Means Committee advanced four opioid crisis-related packages. The bipartisan measures, which are expected to move with other House bills under consideration, largely focus on combating the epidemic through strengthened prevention, provider and beneficiary education, and treatment options. During the markup, Ways and Means Chairman Kevin Brady (R-TX) … Continue Reading
Last week, CMS announced that it intends to reopen the submission period for hardship exception applications for eligible professionals and eligible hospitals to avoid the 2015 Medicare payment adjustments for not demonstrating meaningful use of Certified Electronic Health Record Technology (CEHRT). This reopening process will be addressed through future rulemaking. Previously, the hardship exception application … Continue Reading
Given the 880,000 names of physicians released by Medicare Wednesday, physicians who treat Medicare patients can expect their names to be on the list. The list, searchable here, contains the name of the provider, the specialty area, the city, county and state as well as the total payments made to the provider by Medicare for … Continue Reading
The Florida legislature is currently considering proposed legislation that may affect the way in which managed care organizations, insurers, third-party payors, pharmacy benefit managers and other entities audit pharmacies in Florida. The Florida House of Representatives, Health Innovation Subcommittee, is reviewing HB 745, which proposes to create a “Pharmacy audit bill of rights.” The Health … Continue Reading
On January 10, 2014, CMS will publish the proposed rule titled Medicare Program: Contract Year 2015 and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (the “Proposed Rule”). The Proposed Rule propositions extensive reforms to the Medicare Advantage (“Part C”) and Medicare Prescription Drug Benefit Program (“Part D”), partly through … Continue Reading
Last Thursday, September 12, 2013, the Department of Health and Human Services (“HHS”) reported that the rate review provisions (the “Rate Review Provisions”) of the Affordable Care Act (“ACA”) saved an estimated $1.2 billion on health insurance premiums in 2012 for 6.8 million policyholders. The Rate Review Provisions are intended to increase transparency behind premium … Continue Reading
On April 1, the Centers for Medicare & Medicaid (CMS) backtracked on planned cuts of 2.2% to Medicare Advantage (MA) plan payments for 2014 that were announced in February, and, instead, raised its final estimate of the combined effect of the National MA Growth Percentage and Medicare Fee-for-Service Growth Percentage to an increase of 3.3%. … Continue Reading
