Archives: Reimbursement

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Settlement With DOJ Opens a New Chapter For Tuomey

The cautionary tale of Tuomey (summaries can be found here and here), which illustrated the risks for hospitals structuring arrangements with physicians, is finally coming to a close. When the U.S. District Court for the District of South Carolina first ordered Tuomey Healthcare System, Inc. (“Tuomey”) to pay $237 million for violations of the Stark … Continue Reading

CMS Surreptitiously Proposes to Amend the Two-Midnight Rule Before the Fourth of July Weekend

Like an episode of The West Wing, CMS followed the venerable tradition of announcing “bad news” before the start of a long holiday weekend.  Last Monday, we predicted that the Medicare Payment Advisory Commission’s (MedPAC) June Report would be the final straw to pressure CMS to amend its controversial Two-Midnight Rule. Two days later, on … Continue Reading

The Hits Keep On Coming for CMS – MedPAC Supports Rescission of the Two- Midnight Rule

The Medicare Payment Advisory Commission (MedPAC), recently issued its June Report to Congress.  Echoing the comments of the healthcare community, MedPAC recommended that CMS rescind its Two-Midnight Rule. As a reminder, CMS implemented the Two-Midnight Rule in the FY 2014 IPPS Rulemaking. There are three main elements to the Rule: Amended the definition of “inpatient” … Continue Reading

CMS Finalizes Medicare Part C and Part D Program Changes for Contract Year 2015: Moderate Deviations from Proposed Rule

On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare … Continue Reading

Is Your Name on the List?

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

CMS Adds to the Growing Guidance on Third Party Premium Payments

On February 7, 2014, the Centers for Medicare and Medicaid Services (CMS) issued a memorandum that adds to the growing library of federal guidance on the permissibility of and limitations for health care providers and other entities paying the premiums of patients covered by qualified health plans (QHPs) in the health insurance exchanges or marketplaces.  … Continue Reading

CMS Ushers in the New Year with Medicare Part C and Part D Proposed Rules: HHS Hopes to Save $1.3 Billion

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

District Court Deals Major Blow to Halifax in Bank Busting Qui Tam Suit

On November 13, U.S. District Court Judge Gregory A. Presnell of the Middle District of Florida partially granted the U.S. government’s summary judgment motion against Halifax Hospital Medical Center (“Halifax”).  Judge Presnell ruled that Halifax failed to demonstrate that bonus compensation arrangements it made with medical oncologists satisfied a Stark Law exception.  Judge Presnell found … Continue Reading

Tuomey Ordered to Pay $237 Million

Capping a case that has drawn the attention of healthcare lawyers and hospital executives nationwide, the U.S. District Court for the District of South Carolina has ordered Tuomey Healthcare System, Inc. (“Tuomey”) to pay over $237* million for violations of the Stark Law and False Claims Act arising from certain employment agreements between Tuomey and … Continue Reading

Corporate Health Exchanges: The Next Big Thing in the Obamacare Era?

Last Wednesday, September 18, 2013, Walgreen Company (“Walgreen”) announced its plan to move approximately 160,000 employees to Aon Hewitt’s private health exchange (the “Aon Exchange”) in 2014. This move marks a significant decrease in risk for Walgreen as the company will shift to a defined contribution model for funding its employees’ health insurance. Under the … Continue Reading

HHS Releases “Rate Review” Impact Data: Policyholders Save $1.2 Billion Nationwide

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

CMS Pledges to Reassess All Critical Access Hospitals’ Certification

In response to a recently released Office of Inspector General (“OIG”) report that concluded CMS is overpaying many Critical Access Hospitals (CAHs), CMS pledged to reassess all CAHs’ certification.  The report asserts that CMS could realize substantial savings by decertifying non-compliant CAHs because nearly two-thirds of CAHs would not meet the location requirements if required … Continue Reading

Physicians Practice Interview on ACO Payments: Risk, Reward, and Reviewing Your Healthcare Partners

We’re getting some good traction in the hospital and physician trade press regarding our analysis of the ACO regs. I provided an interview with Physicians Practice discussing the shared savings models of the proposed rules for accountable care organizations and balancing risk versus reward in establishing new health care partnerships.  The interview centered on how the … Continue Reading

ACOs: Will High Start up Costs and Downside Risk Limit Interest in This Health Care Reform Darling?

Providers considering applying to CMS to become an ACO should be aware that the proposed ACO rules are modeled in significant part after Medicare’s Physician Group Practice demonstration project.  Five years in the planning and launched in April 2005, the PGP Demonstration included 10 multi-specialty group practices in various regions of the country comprised of … Continue Reading

Prospective or Retrospective Beneficiary Assignments to Calculate Eligibility for Shared Savings

CMS has considered two basic options for assigning beneficiaries to an ACO to calculate eligibility for shared savings.  The first option is that beneficiary assignment would occur at the beginning of the performance year on a prospective basis.  The second option is for beneficiary assignment to occur on a retrospective basis based on the actual … Continue Reading

Introducing Risk Through a Shared Savings Program: The Two-Sided Model – A Carrot and Stick Approach

The Accountable Care Act permits the Secretary of HHS to implement partial capitation models or any other payment model the Secretary determines will improve quality and efficiency. The Proposed Rule states that the Secretary will test partial capitation models in the Innovation Center. Pursuant to the “other payment model” authority, however, the Proposed Rule would … Continue Reading
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