Compliance Takes Center Stage in the Magic Kingdom

There’s nothing quite like Disney World: you’ve got the rides, the characters and last week, a whole passel of health-care compliance officers. That’s right, I’m talking about the Health Care Compliance Association’s Compliance Institute, and this year, the conference unveiled a new guidance for health-care boards on their compliance oversight.

How are Health Plans Covering Contraceptives Under the ACA?

Even though the Affordable Care Act requires health plans to cover contraceptive services without out-of-pocket costs for enrollees, there’s a lot of variation in what plans are doing, according to a report from the Kaiser Family Foundation (KFF).

Telehealth Industry Feels Some Love

After years of pushing for higher levels of Medicare reimbursement for physicians providing telehealth services and tracking their patients’ health via remote patient monitoring tools, technology advocates say they’re finally expecting some significant wins this year.

Consumers Have More Choice of ACA Networks, But There’s a Price Trade-Off

Limits on medical providers covered by Affordable Care Act (ACA) health plans have been a hot topic for consumers and regulators. But a study by McKinsey & Company found that consumer choice has greatly expanded in the ACA exchanges with over 1,000 new hospital networks introduced in 2015.

More Than 68,000 Uninsured Sign Up for ACA Coverage

More than 68,000 uninsured consumers who owe a penalty under the Affordable Care Act (ACA) took advantage of a special enrollment period to sign up for health-care coverage as of April 13, the Department of Health and Human Services (HHS) said.

Medicare Sustainable Growth Rate Repeal Bigger Than Obamacare

A law that finally ends the reviled Medicare “sustainable growth rate” payment system for doctors will also make major changes in the way health insurers pay for health care for the rest of Americans, health-care analysts say.

SGR Is No Longer the Law, But A lot of New Fraud Provisions Are

 Now that the president has signed H.R. 2 into law, much of the buzz has been about the law’s goal of transitioning Medicare to a value-based payment system. However, several new anti-fraud provisions were also tucked into the bill, all of which will have an impact on providers and beneficiaries.

The SGR is Dead. Long Live the SGR.

President Obama April 16 finally put an end to years of patches and threats of payment cuts to doctors by signing into law legislation (H.R. 2) that would permanently replace the controversial sustainable growth rate formula for calculating Medicare physician payments. The law was passed overwhelmingly by the Senate during a late-night vote April 14, 92-8. That vote followed the bill’s passage in the House by a 392-37 count.

It’s Rulemaking Time at CMS

The first in series of big Medicare proposed payment rules due out in the next few months was released April 16 as the Centers for Medicare & Medicaid Services announced that pay to nursing homes would rise $500 million, or 1.4 percent, in fiscal 2016.

AMA Fights Back Against CMS’s Actuary Report on SGR

The CMS’s chief actuary recently threw a bit of cold water on the momentum of Congress trying to pass a permanent repeal of Medicare’s sustainable growth rate. Paul Spitalnic, the agency’s chief actuary, said in an April 9 report that the Medicare legislation (H.R. 2) that’s poised for a Senate vote this week won't be the final step to solving the SGR problem.

Will Private Health Insurance Exchanges Overtake Affordable Care Act Exchanges?

Health insurance exchanges, online marketplaces where consumers can easily compare plans and sign up for coverage, have gained momentum from the Affordable Care Act, and now they are taking off in the private exchange market, according to an analysis by management consulting and technology company Accenture.

Another Argument for Extending CHIP: Plans Are Cheaper Than in the Exchange

Experts and advocates agree that the insurance exchanges aren't ready to support children the way the Children's Health Insurance Program can, and a recent report by the Government Accountability Office backs that view. According to the report, children enrolled in CHIP plans generally will pay less for the same services that are offered under private plans in state insurance exchanges. 

Premium Tax Credit Payments on the Rise

The first four months of fiscal year 2015 were very good for the insurance exchanges’ advance premium tax credit program, with CMS disbursing $5.8 billion. This compares with the $11 billion CMS disbursed for all of FY 2014, according to a recent report from the OIG and the Treasury Department.

White House Economic Adviser Says ACA Improves U.S. Economy

The Obama administration is trying to fight back against charges that the Affordable Care Act hurts the U.S. economy. In a presentation given April 2 to the liberal Center for American Progress, White House Council of Economic Advisers Chairman Jason Furman asserted that not only have dire predictions made by ACA critics not come to pass, but the health care law is having many positive economic effects.

Do Hospitals Want to Penalize the RACs?

It’s a well-known fact that hospitals aren’t the biggest fans of the RAC program, with complaints ranging from increased administrative burdens associated with RAC audits to improper claims denials.

Patent Eligibility Crisis: The Result of Many Things

A noted life sciences patent attorney said at a conference I attended that the current crisis in patent eligibility for applicants with nature-based claims is the product of not one cause but many.

Failed 'Doc Fix' Vote Leaves Providers in Limbo

A 21 percent pay cut to doctors' Medicare reimbursements is scheduled to take effect April 1 after the Senate punted on an immediate vote on a bill to permanently repeal and replace Medicare's sustainable growth rate. The Senate left town after an all-night budget "vote-a-rama" session ended March 27 without a vote on the bill (H.R. 2).

Many With Chronic Conditions Had to Switch Doctors, Medicines in ACA Plans

Nearly a third of enrollees in Affordable Care Act exchange plans who had chronic conditions had to switch doctors because their doctor wasn’t in the plan they chose and more than a quarter had to switch their medication, according to a survey of 412 patients conducted by a group that represents such patients.


Increased Medicaid Oversight on Tap for the OIG

The Medicaid program got a big expansion courtesy of the ACA, and along with it is coming increased oversight from the OIG. I was up in Baltimore this week at an AHLA conference and heard Greg Demske, chief counsel at the OIG, who said the agency is reviewing how Medicaid expansion states are categorizing their beneficiaries.

The End of the SGR May Be Near

Congress this week may finally pass legislation repealing and replacing Medicare’s sustainable growth rate formula , words physicians, health care lobbyists, and health care reporters have been waiting to hear for a decade.

Is the Sequester Hurting Anti-Fraud Efforts?

If you talk to most people in Washington, they’ll tell you they don’t like the sequester. With the recent release of the annual HCFAC report, HHS and DOJ may be joining those ranks. The report said federal government anti-fraud efforts led to $3.3 billion in recoveries in FY 2014, a decline from the $4.3 billion recovered in FY 2013.

Antibiotics Development Down, Congress, FDA Catch Up

The restaurant chain McDonald's March 4 decision to address the problem of drug resistance deserves attention but still leaves a less-than-robust antibiotics pipeline that stakeholders have to work hard to correct, an noted economist told me.

Great Discovery, But Maybe No Patent

Obtaining patents covering medicines based  on natural products isn't easy. The first antibiotic to be discovered  in 30 years,  which has excited the NIH director and members of Congress, was  denied patent protection by the Patent and Trademark Office.

HHS Reports 11.7 Million Enrollees in ACA Marketplaces for 2015

More than 8.8 million people enrolled in Affordable Care Act health plans through the federal marketplace for 2015, and nearly 7.7 million of them – about 87 percent – qualified for an average tax credit of $263 a month, according to a report released March 10 by the Department of Health and Human Services. The figures are based on enrollment through Feb. 22, and don’t include data on how many have paid premiums.

Meaningful Use Program Sees Only Slight Uptick in Provider Attestations in February

February saw only a slight increase in the number of physicians who attested to meeting requirements of the meaningful use program, leaving overall provider participation in the program relatively low just weeks before the final deadline, according to data released recently by the Centers for Medicare & Medicaid Services.

J.D. Power Finds Improved Customer Satisfaction With Health Plans

Notwithstanding the traumatic launch of the Affordable Care Act’s health insurance marketplaces in 2013 and ongoing controversy over the limited networks of medical providers featured by many marketplace health plans, member satisfaction has increased significantly as plan administrators take a “customer-centric approach,” according to the J.D. Power 2015 Member Health Plan Study released March 9.

How Much Support do RACs Have on MedPAC?

Apparently, very little, given that a set of draft recommendations that would change how Recovery Audit Contractors operate were unanimously supported by members of the Medicare Payment Advisory Commission (MedPAC).

GAO Finds Many Weaknesses Not Fully Corrected

The problems that plagued the federal enrollment site for Affordable Care Act health insurance have been significantly reduced since its “troublesome launch” in October 2013, but many of its weaknesses haven’t been fully corrected, the Government Accountability Office said in a report released March 4.

Time to Get Ready for OIG Marketplace Reviews

While the OIG has a lot on its plate when it comes to reviewing the Affordable Care Act, nothing looms larger than the health-insurance marketplaces. A recent document from the OIG affirmed that the marketplaces will be the chief focus of the OIG’s ACA oversight in 2015, and upcoming reviews will look at payment accuracy, eligibility and information security.

Melanoma App Marketers Settle FTC Complaints, Spur Oversight Concerns

The marketers of two mobile health applications that ostensibly detect skin cancer have agreed to settlements with the Federal Trade Commission that forbid them from making further claims that their apps can analyze a mole's melanoma risk, the FTC announced recently.

More Than Half of ACA Subsidy Recipients Must Repay Some Portion

Fifty-two percent of the clients seen by H&R Block Inc. who received subsidies through the Affordable Care Act in 2014 underestimated their income and must repay a portion of the subsidies, with the average repayment $530, according to a Feb. 24 release from the Kansas City, Mo.-based company.

What do RACs Think of Hospitals’ Efforts to Change Short-Stay Policies?

Recovery Audit Contractors (RACs) view attempts by providers to change reimbursement levels for short-term hospital admissions as part “of an ongoing effort on the part of the hospital industry to weaken oversight,” a spokeswoman for the American Coalition for Healthcare Claims Integrity (ACHCI), a trade association for the RACs, told me Feb. 17.

Is CMS Reimbursing Doctors Who Have Delinquent Debts?

It’s fairly simple: if you owe money to someone, they shouldn’t be giving you more until you’ve paid off your debts. At CMS however, the opposite seems to hold true, as a recent report from the OIG discovered.

HHS Allows Extra Time for ACA Enrollment

As it did last year, the Department of Health and Human Services is allowing extra time for people who were “in line” to sign up for Affordable Care Act coverage when open enrollment ended Feb. 15.

HealthCare.Gov Third-Party Tracking Was Overkill, Consultants Say

An Associated Press (AP) story published in January reporting that “dozens” of data companies tracked consumers on the federal marketplace prompted a congressional hearing Feb. 13 by two subcommittees of the House Committee on Science, Space, and Technology.

Will CMS’s New Five-Star Quality Rankings Cast an Unfair Light on Nursing Homes?

The Centers for Medicare & Medicaid Services will unveil Feb. 20 the latest version of its Nursing Home Compare website, which includes an updated five-star quality rating system with higher standards, and nursing homes say the new system may mistakenly convey to public that quality of care is declining in the industry.

Is the Verdict Still Out on ICD-10 Implementation?

ICD-10 implementation is set for Oct. 1, but having already been delayed twice, are we going to make it this time? I recently attended an Energy and Commerce subcommittee hearing on transitioning to ICD-10, and judging by member comments, there’s a definite split over the possibility of another delay.

CMS to Penalize Doctors $200M for Failing to Participate in Meaningful Use

The federal government in 2015 will pay an estimated $200 million less in reimbursements to the 256,000 doctors who failed to participate in the Medicare Electronic Health Record Incentive program, according to Centers for Medicare & Medicaid Services data and officials' comments Feb. 10.

As Doc Fix Cost Rises, Hopes for Permanent Solution Fall

Congress has begun its annual quest to avert the steep cuts to physician payments by repealing Medicare's sustainable growth rate (SGR)-- a funding disaster of its own making. Every year, Congress passes a patch that saves doctors from getting their payments from Medicare cut by over 20 percent.

87 Percent of Federal ACA Enrollees Will Get Average of $268 in Monthly Subsidies

Highlighting the significance of subsidies for people who sign up for Affordable Care Act health plans through the marketplace run by the federal government in 37 states, the Department of Health and Human Services released a report Feb. 9 that said that 87 percent of individuals who have selected plans for 2015 – almost 6.5 million people – qualify for advance premium tax credits averaging $268, or 72 percent, of the monthly premium.

Providers Seek More Shared Savings Under ACO Program

The Medicare Shared Savings Program (MSSP), which governs accountable care organizations, should be changed to provide more opportunity for providers to garner savings while being exposed
to less financial risk, providers have told the Centers for Medicare & Medicaid Services.

Can Providers Give Out Free Diapers and Playpens to Medicaid Patients?

Here’s the scenario: a provider offers free diapers and playpens to Medicaid patients if they sign up for a state-run maternal health program and select the provider for their medical services. While it may seem like a potential violation of the anti-kickback statute, a recent OIG advisory opinion begs to differ. The OIG said it wouldn’t impose any administrative sanctions or civil monetary penalties over the penalty, but did note that the advisory opinion only covers the individual arrangement.

How Would the President’s Budget Proposal Reduce the Medicare Appeals Backlog?

The president's fiscal year 2016 budget request seeks a more than a three-fold increase in funding to help address a backlog of Medicare appeals. However, hospital groups told me that other changes to program are needed if the administration is serious about cutting down on the number of Medicare cases at 800,000 cases at the administrative law judge (ALJ) level of appeals.

What’s On Tap for the OIG in 2015

I recently had a chance to interview Christi Grimm, the OIG’s chief of staff, and she told me that the coming year will see more OIG reviews of the health insurance marketplaces, the ongoing Medicaid expansion courtesy of the Affordable Care Act and patient quality-of-care issues.

Anti-Fraud Funding Would Get a Boost from President’s Budget

While Republicans and Democrats rarely agree on matters of policy, Medicare and Medicaid anti-fraud efforts are generally a rare area of agreement, which could signal success for some of the administration’s proposals contained in the recently released fiscal year 2016 budget.

CMS to Shorten Meaningful Use Reporting Period in 2015

A new rule this spring will propose changes to the Medicare and Medicaid Electronic Health Record Incentive programs in 2015, including a shortened reporting period to make it easier for providers to comply with program requirements, a Centers for Medicare & Medicaid Services official announced Jan. 29.

How will HHS Enforce Its New Medicare Payment and Quality Goals?

It’s a question that’s been on the minds people in the health policy world ever since Health and Human Services (HHS) Secretary Sylvia Mathews Burwell Jan. 26 announced goals and a timeline to move the Medicare program, and the health-care system at large, toward paying providers based on the quality, rather than the quantity, of care they provide.

Are Physicians Aware of the Face-to-Face Requirement?

It seems like a pretty straightforward requirement: under Medicare regulations, physicians must have a face-to-face visit with a patient before they write up a prescription for a power wheelchair or scooter.

Stakeholders Set Sights on Transformed Health Care System

A group of health-care systems, health insurers and purchasers announced Jan. 28 creation of an alliance that will work toward a goal of getting 75 percent of its business under value-based payment arrangements by 2020.

Advocates Eyeing ACA `Essential Health Benefit’ Requirements for 2016

The plan for designating benefits that must be covered by most health plans in the individual and small group markets is set to expire at the end of 2015, so advocacy groups are starting to push for what they want to see the Department of Health and Human Services issue for plan years starting in 2016.

Democrats Argue Raising ACA Definition of Full-Time Work Increases Cutbacks

One of the first actions taken in the new Republican Congress to change the Affordable Care Act is to amend the law’s definition of full-time work, which determines who companies that employ at least 50 employees must offer “affordable” coverage that provides “minimum value.”

Is Oversight Lacking for Hospital Use of Compounded Drugs?

There’s no doubt that compounded drugs can carry high risk: Just go back to 2012 when contaminated steroid injections manufactured by the New England Compounding Pharmacy led to a fungal meningitis outbreak and killed 64 people.

HHS OIG Defends Hospital Compliance Reviews

The HHS Office of Inspector General is rejecting criticism about its hospital compliance reviews, saying it hopes hospitals will use the reviews to reduce the number of Medicare billing errors and to strengthen compliance.

Top 10 Life Sciences Topics in 2015

Patents and biosimilars again will be important issues for the life sciences industry in 2015, as will health information technology and Food and Drug Administration oversight of laboratory developed tests (LDTs), a new survey predicted.

The First ACA Tax Filing Season Could Have Problems

The Department of Health and Human Services is distributing forms that will be needed by millions of people who received premium tax credits to help them pay for health insurance from the Affordable Care Act marketplaces.

Bloomberg BNA Event: Experts Weigh in at 2015 Outlook on Health Care

Health insurance legal and regulatory thought leaders from BNA’s Health Insurance Report Advisory Board shared their thoughts and predictions with a live audience Jan. 14 at Bloomberg Government offices in D.C.  for a lively discussion of top health  insurance issues for 2015.

Who Should Regulate Lab-Developed Tests?

The question has caused a major uproar in the health policy circles ever since July, when the Food and Drug Administration notified Congress it would propose a regulatory oversight framework for laboratory-developed tests (LDTs), a type of diagnostic tests.

Top 10 Health IT Topics in 2015

A survey of Bloomberg BNA's Health IT Law & Industry Report's Advisory Board members determined that the top 10 health IT issues for 2015 are...

When Are Workers Considered Full Time?

Under the Affordable Care Act, anyone who works at least 30 hours a week is considered full time, and employers must provide those employees with health insurance. But a bipartisan group of House and Senate lawmakers are attempting to get that changed.

Wide-Ranging ACA Proposed Rule Draws Comments on Prescription Drugs

Nov. 21 the Centers for Medicare & Medicaid Services released a wide-ranging proposed rule under the Affordable Care Act covering everything from how health insurers’ rates will be reviewed in 2016 to who will be exempt from the law’s individual mandate.

Some State ACA Exchanges Extend Deadlines, Open Storefronts

State-run Affordable Care Act health insurance exchanges in California and New York have delayed their deadlines to sign up for Jan. 1 coverage to Dec. 21 and Dec. 20, respectively, while Washington state has always had a Dec. 23 deadline, exchange officials said in a Dec. 17 press briefing sponsored by health-care consumer organization Families USA. Officials from those states and Kentucky gave enrollment updates and described lessons they learned from 2014 in the briefing. The federal deadline to sign up for Jan. 1 coverage was Dec. 15.

Nearly 2.5M Select Plans Through Federal ACA Exchange, HHS Says

Nearly 2.5 million consumers have selected health plans through the federal government's website between Nov. 15 and Dec. 12 under the Affordable Care Act, the Department of Health and Human Services reported. More than 1 million consumers selected plans in the past week.

Health Insurance Industry Leader Calls For Drug Development Cost Transparency

Karen Ignagni, head of America's Health Insurance Plans, which represents most U.S. insurers, Dec. 12 called for greater transparency concerning drug development costs so that the public could determine how much is spent on research and development. The drug industry has argued that high research and development costs justify high prices for drugs, in particular skyrocketing prices for specialty drugs. The health insurance industry has been highly critical of the drug industry for "unsustainable" drug costs.

CMS Proposes Coverage Revisions for Same-Sex Spouses

The CMS Dec. 11 released a proposed rule to revise selected conditions of participation and coverage for providers, suppliers and long-term care facilities to ensure they are consistent with a Supreme Court decision invalidating provisions of the Defense of Marriage Act.


Most ACA Consumers Could Save Money if They Shop for Plans in 2015, HHS Says

More than seven in 10 consumers currently enrolled in Affordable Care Act marketplace plans can find a lower premium at the same "metal level," before federal tax credit subsidies are taken into account, if they return to the marketplace to shop, according to an analysis released Dec. 4 by the Department of Health and Human Services.

Are the OIG's Hospital Compliance Reviews Fair?

It's been several years now since the OIG began conducting hospital compliance reviews, and to say the reviews have been unpopular is a bit of an understatement. The AHA recently sent a letter to...

State Insurance Regulators Consider New Regulations for Health Insurance Networks

A model law on health plan networks being drafted by the National Association of Insurance Commissioners (NAIC), which represents state regulators, will likely cover all types of health plans, including qualified health plans sold under the Affordable Care Act, a NAIC official said Nov. 19. But the model law isn't likely to include standards governing the length of time it takes plan enrollees to get appointments with providers or the distance they would have to travel. CEO Offers Possibilities for States To Create ACA Marketplaces

Kevin Counihan, CEO of the federal ACA enrollment site, told state insurance commissioners Nov. 18 that states may have a number of options to be considered state-based marketplaces if the U.S. Supreme Court overturns an IRS rule allowing premium subsidies to be issued to enrollees in federally-run marketplaces.

State ACA Marketplaces Increasing In-Person Assistance

More in-person assistance will be available for people enrolling for health coverage in 2015 in the Affordable Care Act marketplaces, the directors of marketplaces operated by California, New York, Washington and Kentucky said in a press briefing Nov. 12. The second ACA open enrollment period, from Nov. 15 through Feb. 15, 2015, is half the amount of time of the first open enrollment in 2013-2014, and people who didn't enroll during the first open enrollment period will be harder to reach.

Does an Ebola Outbreak Trump the HIPAA Privacy Rule?

While the HIPAA Privacy Rule protects personal health information (PHI) from being released without patient permission in most situations, there are some exceptions, as a recent HHS Office for Civil...

Confused by the ACA's “Narrow Networks?” Physicians Are Too.

Doctors in Affordable Care Act marketplace plans offered by Blue Shield of California were confused about whether they were in the plans' networks, often telling consumers that they weren't part of networks that they actually were part of, a company executive said Nov. 7 at a conference. A Georgetown University professor also told the conference that quality generally wasn't a consideration when companies set up their ACA networks; rather, it was just a matter of signing up providers who would take a discount.

ACA Premiums Up As Much as 78 Percent in 2014 Over 2013

Unsubsidized health insurance premiums in the individual market increased between 23 percent and 78 percent for men and women of different ages after the Affordable Care Act took effect in 2014, according to health insurance research organization HealthPocket. The highest increase was for 23-year-old nonsmoking men, while the lowest increase was for 63-year-old men. The ACA's prohibition on rate-ups or rejections of people with medical problems was a key factor, the health plan rating company said.

Will ACA Subsidies End up Like Medicaid?

If courts overturn an Internal Revenue Service rule allowing people buying health insurance in the Affordable Care Act's federally-run marketplaces to get subsidies, states will have to be convinced to set up their own marketplaces one at a time in a process similar to what is taking place with Medicaid, an ACA supporter says.

Is IT’s Luster Lost on Doctors?

The American Medical Association isn’t pulling punches when it comes to EHRs and other technologies the federal government is pushing in the name of improving patient care and cutting costs.

CMS Attempting to Jump-Start ACO Program

The CMS is attempting to jump-start growth in the Accountable Care Organizations program by providing $114 million in funding for infrastructure investments and care management improvements. ...

Why are Copays So High for Critical-Access Hospitals?

While everyone's familiar with what a copayment is, they might not know that there's a big difference in copayments between critical-access hospitals (CAHs) and acute-care hospitals. A recent OIG ...

2015 Part B Premium, Deductible Unchanged, CMS Says

The HHS says 2015 Medicare Part B premiums and deductibles will remain the same as they have for the last two years, due in part to lower program growth since passage of the Affordable Care...

Notes from AHLA's Fraud and Compliance Forum

I recently spent two days in Baltimore, home to the AL East champion Orioles and the site of the AHLA's 2014 Fraud and Compliance forum, and thought I'd pass on a few takeaways. The forum kicked off...

WellPoint, Gilead Debate Drug Costs

Since the “$1,000 a pill” wonder drug Sovaldi has been making headlines for its success at curing hepatitis C, health insurers have ramped up a campaign to rein in soaring costs for specialty...

Finding a Safe Harbor in Anti-Kickback Seas

Safe harbors always sound like a good thing, especially when they offer protection against the anti-kickback statute, and a recent expansion proposed by the OIG is sure to please providers. The...

Let the Sunshine in, Open Payments is Finally Here

After months of anticipation (and not a little angst from physicians and drug and device manufacturers), CMS has publicly released the Open Payments database, and as we head into this new phase in...

Revisiting ICD-10, Again

I recently attended a congressional staff briefing sponsored by the Coalition for ICD-10, and the takeaway from the panelists was as clear as it gets: don't delay ICD-10 again. A mixture of...

Solving the Mystery of What Scalia Said

A federal district court judge attempted to solve a mystery in what is known as the Myriad gene patent case: why did Supreme Court Justice Antonin Scalia concur with everything about the opinion...

Judge Says Cases Define What It Means to Be Human

A federal district court judge told a conference Sept. 12 that recent cases on gene patents and bioethics issues will be long remembered because they are defining what it means to be human. ...

Is Context Key for Open Payments Program?

Context is often the key to understanding jokes, anecdotes and any other fun bits of information, and if three industry associations are to be believed, it's also key to understanding data in CMS's...

ACOs Improve Quality, Save Money, CMS Says

Accountable care organizations created under the Affordable Care Act are meeting their goals of improving patient care while saving Medicare money, the Centers for Medicare & Medicaid...

Hackbarth To Leave MedPAC After 15 Years

Medicare Payment Advisory Commission Chairman Glenn Hackbarth, who was first appointed to the commission in 2000, will leave the panel in April 2015. He has been chairman since 2001. A resident...

ACA Tax Rule Gets Rehearing By Federal Appeals Court

The full U.S. Court of Appeals for the District of Columbia Circuit will rehear a case on Affordable Care Act tax subsidies, a move that may reduce the chances of a new Supreme Court showdown...

Will We Ever Get New RAC Contracts?

Seems like it was just yesterday that CMS said new RAC contracts would be in place by February of this year. That got delayed, of course, and now it looks like we're in store for more RAC contract...

Open Payments Is Back Online

Last Friday was a banner day for CMS, as it was finally able to put the Open Payments system back online. The database had been offline for 12 days (since Aug. 3) due to an investigation into a...

Is the Sunshine Act on the Cusp of a Delay?

Last week CMS announced it was temporarily taking the Open Payments system offline, due to potential issues involving the review and dispute process for physicians. According to CMS, the review and dispute process, which was supposed to be finished by Aug. 27, will be adjusted for every day the Open Payments system is offline.

Kitchen Sink Draft Bill Covers a lot of Anti-Fraud Territory

In an effort to add more teeth to Medicare fraud fighting, a Republican congressman has released a discussion  draft bill  packed with a kitchen's sink worth of provisions, including removing Social Security numbers from Medicare cards and mandating MACs to create provider outreach and education programs focused on lowering improper payments.

Are We Going to Have to Wait Six More Months for the Sunshine Report?

September is around the corner, bringing with it a new school year, football and the eagerly anticipated public report from the CMS Open Payments program. However, that deadline is being aggressively questioned by the American Medical Association and over 110 state medical groups and industry associations, which have called on CMS to push the report back to March 31, 2015.  

Balance Called For With Narrow ACA Networks

One of the hot topics about the Affordable Care Act is that it has led to more limited provider networks in the health plans sold through the ACA marketplaces. But a panel that briefed reporters on...

RACs Are Back, Albeit on a Limited Basis

Providers, it's time to get ready, because RAC audits are back. RACs have been on hiatus since a February suspension of the ability to request documents associated with claims reviews, but a recent CMS notification announced a limited restart of the program that could continue until new RAC contracts are awarded.

Medicare Won't Go Bankrupt Until 2030

The medicare part A Trust Fund won't go bankrupt until 2030 under new projections, but the entire Medicare system is still in dire need of reform.

Second Bundled Payment Experiment Fails, RAND Reports

The Affordable Care Act authorizes a wide variety of health care payment reforms intended to reduce cost and improve the efficiency and quality of the American health care system. One of the leading...

CMS Releases Three Medicare Payment Rules

The Centers for Medicare & Medicaid Services July 31 released three Medicare final payment rules for fiscal 2015 affecting nursing homes, inpatient rehabilitation facilities, and inpatient...

Is Change Afoot for the False Claims Act?

The winds of change may soon be blowing over the False Claims Act, courtesy of a proposal that would seek to increase the amount of self-reported FCA violations. I attended a Congressional hearing this past week that featured testimony from an attorney who said incentives should be added to the FCA to encourage companies to create certified compliance programs.

Temporary Moratoria Are Back- At Least for Six More Months

If you're a home health agency or ambulance supplier looking to enroll in Medicare in the Houston area, you're out of luck, at least for the next six months. CMS recently announced it was extending temporary enrollment moratoria for HHAs and ambulance suppliers operating in several metropolitan areas.

OIG Turns Up the Heat on Medicare Overpayments

In a story that seems to repeat itself over and over, the OIG has uncovered more improper Medicare payments, this time associated with Medicare administrative contractors (MACs).

Courts Issue Dueling Rulings in ACA Subsidies Cases

C ompeting federal court decisions July 22 left up in the air whether federal subsidies provided individuals enrolling in health insurance coverage under the Affordable Care Act are legal....

HHS Issues Interpretation of 340B Program Discounts

Despite an adverse court decision, the federal government is maintaining its position on how safety-net providers can receive discounts on drugs that may have “orphan” uses. The HHS July 21...

Federal Government Scores Another Win Against Health-Care Fraud

The Department of Justice scored another win in the on-going fight against health-care fraud with the recent announcement of a guilty plea by an executive of Alpha Diagnostics, a supplier of portable x-ray services based in Owings Mills, Md.

Industry Associations Not Happy With OIG Proposed Rule on Exclusions

It's official: Industry associations aren't happy with a recent proposal from the OIG increasing the agency's exclusion authority. Comment letters from the AMA, the AHA and PhRMA all took issue with the proposed rule, especially a provision that would abolish the current six-year statute of limitations for imposing exclusions on individuals or entities.  

Battle Lines Drawn Between Providers and RACs

The battle is really shaping up between RACs and hospitals and physicians, as evidenced by a recent Senate staff report and roundtable meeting. I was at the Senate Special Committee on Aging roundtable, where a range of participants representing both providers and RACs sparred over the effectiveness of the RAC program, and program integrity contractors in general.

CMS Wants to End Sunshine Reporting Exemption for CME, Or Does It?

Buried inside the 600-plus pages of the proposed 2015 Medicare physician fee schedule is a provision that on first glance looks major: CMS wants to excise an entire section of the Sunshine Act that grants reporting exemptions to manufacturers that fund continuing medical education events.

Milliman Finds Narrow ACA Networks Reduce Premiums

Under the Affordable Care Act health insurers have limited options for reducing premiums in the individual and small group markets, since the law prohibits them from discriminating against people with medical conditions and it requires that a standard package of benefits be covered.

More From AHLA's Annual Meeting: OIG Update

AHLA's annual meeting was so jam-packed with information that I can't resist one more blog post about it, if only to highlight what the OIG has been up to lately. Robert DeConti, the OIG's assistant inspector general for legal affairs, said medically unnecessary cardiac procedures have been on the OIG's radar screen of late

New York, New York: Notes From AHLA's Annual Meeting

I just returned from two-action packed days in New York covering the AHLA's Annual Meeting, and one of my big takeaways is that provider grumbling over the RAC program are starting to gain some some traction within Congress.

Supreme Court Ruling Could Affect Other Employers

While the June 30 Supreme Court ruling that contraceptive coverage regulations implementing the Affordable Care Act's preventive services mandate for women violates the Religious Freedom...

Congress Isn't Happy With CMS, Again

I headed up to the Hill yesterday for yet another Congressional hearing into Medicare fraud, waste and abuse, and as usual, the members weren't happy with the lack of progress CMS has made in protecting the program.

CMS Gets Serious About Plan C and Plan D Oversight

CMS is not pulling any punches when it comes to oversight and enforcement over Medicare Part D and Part C plan sponsors, and the agency has the tools to make any violations hurt, a CMS official said at a recent conference I listened in on via a webcast.

Talking Drug Diversion with the OIG

Prescription drug diversion is a growing problem for the health-care system, resulting in both financial loss and patient harm. Last week I sat down with Leslie Hollie, the OIG's assistant inspector general for investigations, to talk about common diversion schemes and the strategies the OIG is using to fight back.

Choice of Hospital Networks Expanded Under ACA

One of the controversial elements of the coverage provided under the Affordable Care Act is that medical provider networks for which enrollees receive full coverage under the health plans are...

Stark Law Exception Back in Play, Thanks to CMS Notice

My favorite Stark law exception, the in-office ancillary services exception (IOASE) is back in the news, thanks to a recent notice from CMS asking for comments on any burdens associated with the IOASE's disclosure requirement. Self-referring physicians offering imaging services are required to give patients a notice disclosing ownership interests in imaging equipment, and are also required to provide a list of five alternate imaging providers operating within a 25-mile radius.

Does Self-Referral Really Drive Up Patient Visits?

Conventional wisdom has it that self-referring providers are always going to refer more patients for services, but is this actually the case? Yes, according to a recent GAO report, but with a caveat or two.  

Are OIG Hospital Compliance Reviews Too Burdensome?

Continuing its assault on what it consider burdensome audit activities by the federal government, the American Hospital Association has asked the Health and Human Services Department to block future hospital compliance audits conducted by the HHS Office of Inspector General. A recent letter from the AHA to the HHS and the Centers for Medicare & Medicaid Services said the OIG reviews often overlap with Recovery Audit Contractor (RAC) reviews, presenting hospitals with an onslaught of contractors all asking to review the same records.

Growth in Individual Health Insurance Market

Much data remains to be revealed about the Affordable Care Act, and a key issue is whether it is resulting in greater health insurance coverage.  The Kaiser Family Foundation (KFF) took a stab at...

Do RACs Really Add to Hospital Burdens?

RACs have been operating nationally for several years now, but a question that's often asked is whether they're merely adding to the administrative burden facing hospitals rather than accomplishing their original mission by identifying and recovering overpayments. An answer to that question was included in the recent RACTrac survey from the American Hospital Association, which said said that 48 percent of hospitals reported spending over $25,000 to manage their RAC process during the first quarter of 2014, while 11 percent reported spending over $100,000.

White House Advisors Call for Ending Fee-for-Service

The latest in a string of criticisms of the way the nation pays for health care services came May 29 from a top technical advisory panel to President Obama. The President’s Council of Advisors...

Are Insurance Exchange Subsidies Going to the Right People?

Cost-sharing subsidies and tax credits associated with the health-insurance exchanges are key to reducing costs for people signing up for insurance under the ACA, but there's a chance they might not be going to the right people. Three Republican Senators recently sent a letter to the OIG calling for further review of the procedures and safeguards surrounding exchange subsidies.

ACA Is Getting a Once-Over from the OIG, Report Says

The OIG is expending serious oversight effort on the various provisions of the Affordable Care Act, as attested by the agency's recent semiannual report to Congress. The Inspector General himself, Daniel R. Levinson, said the "OIG has a substantial body of work underway focusing on core risk areas associated with the Marketplaces, such as eligibility systems, payment accuracy, contractor oversight, and data security."

Medicare Appeals Backlog Is Not Getting Any Shorter, and Congress is Angry

The HHS's Office of Medicare Hearings and Appeals (OMHA)  is currently facing a backlog of 460,000 pending appeals, and Congress has had enough. At a recent House subcommittee hearing, lawmakers from both sides of the aisle were resolute in their condemnation of the backlog, and its affects on providers.

Does the Stark Law Apply to Medicaid?

Providers have been grappling with the intricacies of the Stark law for years, with all of the focus on Medicare payments. A recent bill introduced in the House would change that, ensuring that the Stark law would apply to designated Medicaid health services as well.

Feds Flex Enforcement Muscles, Charge 90 With Health-Care Fraud

Whenever I hear the word takedown, I start thinking of Eliot Ness and the Untouchables, rooting out crime in Prohibition-era Chicago. Perhaps that's why DOJ and HHS starting using it to describe their periodic one-day aggregations of health-care fraud indictments. The most recent takedown, based on Medicare Fraud Strike Force investigations, involved charges against 90 individuals in six different cities who allegedly participated in schemes that defrauded Medicare to the tune of $260 million,

OIG Toughens Up on Fraud Penalties

No one wants to hear that they're due for a civil monetary penalty, courtesy of the OIG, but a recent proposed rule could make that scenario a lot likelier. A day after releasing a proposed rule enhancing its exclusions authority, the OIG released another proposal rule, this time broadening the scope of behavior eligible for a CMP.

OIG's Looking to Expand Exclusion Authority

Getting excluded from Medicare and Medicaid is the nightmare scenario for providers and suppliers, and if the OIG gets its way, that exclusion authority will broaden. A recent proposed rule from the OIG would implement several provisions from the Affordable Care Act

Find Yourself a “City” to Live In

CMS is updating the way it classifies labor markets, and shifting populations may mean previously urban hospitals will be rural, and previously rural hospitals will be considered urban.

Massachusetts to Shutter Health Exchange

Massachusetts is throwing in the towel on its ailing health exchange website and will instead connect to the federal website with a unique plug-in, officials announced May 5,...

The Waiting's Over: CMS Confirms New ICD-10 Deadline

After almost a month of uncertainty, CMS has cleared up confusion over the ICD-10 implementation date, confirming that Oct. 1, 2015 is the official deadline. Mention of the new implementation was buried deep within the hospital inpatient prospective payment system proposed rule (page 648 to be precise), and CMS followed up with an announcement that it will shortly release an interim final rule confirming Oct. 1, 2015 as the deadline.

OIG Oversight to Take a Hit Due to Budgetary Shortfalls

HHS's watchdog, the OIG, may soon be doing less watching of Medicare and Medicaid, due to budgetary issues, an OIG official said at a congressional hearing. I was at the recent Ways and Means Subcommittee on Health and heard Gloria Jarmon, the OIG's deputy inspector general for audits, say that the agency expects to cut back Medicare and Medicaid oversight by 20 percent by the end of the year.

CMS to Raise Pay to Health Centers by 32 Percent

Federally qualified health centers will see their Medicare reimbursement rise by about 32 percent under a new prospective payment system unveiled April 29 by the Centers for Medicare &...

Industry Stakeholders Tell CMS To Back Off On Navigator CMPs

While CMS has expressed a desire to make exchange plan navigators eligible for civil monetary penalties, a number of industry stakeholders want any potential CMPs to be both clarified and limited in their scope. The issue revolves around a proposed rule, issued in March, that would authorize CMS to impose CMPs on navigators and other consumer assistance groups guilty of violating federal standards, such as providing fraudulent information to the exchanges or improperly using or disclosing a patient's personally identifiable information.

Improper Payment Rate for Medicare FFS Still Too High

For the second straight fiscal year, CMS has missed the targeted improper payment rate for Medicare fee-for-service, according to findings from a recent OIG  report . The targeted improper payment rate was 8.3 percent, but Medicare reported a 10.1 percent rate.

Anger Growing Over ICD-10 Delay

I went to the AHIMA ICD-10 Summit yesterday, and from my informal polling of some attendees, anger over the ICD-10 delay is growing. The main issue appears to be money: vendors, payers and providers have all spent large amounts of money preparing for the ICD-10 roll-out this coming October, and the delay will cause them to spend even more money.

Industry Coalition Says It's Time to Set a Specific Deadline for ICD-10 Implementation

Everyone knows ICD-10 has been delayed, yet again, but exactly when the new implementation deadline is has been harder to pin down. The official text of the Protecting Access to Medicare Act says ICD-10 implementation may not occur before Oct. 1, 2015, but does not include a specific deadline, according to a recent  letter  sent to CMS by the Coalition for ICD-10, a group that includes America's Health Insurance Plans (AHIP) and the American Hospital Association (AHA), among others.

Is Budget Neutrality Getting in the Way of Serious CMS Savings?

Budget-neutrality rules may be good for controlling the deficit, but they are making it impossible for CMS to realize $15 billion in savings from reducing hospital outpatient payment rates, according to a recent OIG  report . The OIG said that CMS could save $15 billion between 2012 and 2017 if outpatient payment rates for ambulatory-surgical center (ASC)-approved procedures were reduced to ASC levels.

Is Medicare Actually Paying Claims for People Who've Been Kicked Out of the Program?

It seems like an obvious arrangement. If you're enrolled in Medicare, Medicare will pay for your claims, if you're not enrolled, they won't. As obvious as that might seem, a recent OIG  report  discovered that Medicare made $18.4 million in improper payments between 2010 and 2012 on behalf of patients who had been terminated from participating in the program.

Benficiary Beware: Medicaid May Be Sharing Your Information Outside the U.S.

While it's no secret that companies in the private sector routinely outsource administrative functions to foreign contractors, it may come as a surprise that some Medicaid agencies are also engaged in offshore outsourcing. In fact, there are no federal regulations preventing offshore outsourcing, and seven state Medicaid agencies are currently offshoring some of their administrative functions, according to a recent OIG report.

Electronic Fund Transfers Growing Over Expectations

More than 8 million electronic fund transfers (EFTs) totaling $45 billion were made through the Automated Clearing House (ACH) Network in January, the Centers for Medicare & Medicaid Services...

OIG to Physicians: Document Your Face-to-Face Encounters

Even though Medicare is supposed to reject home health claims that don't include documentation that a physician conducted a face-to-face encounter to certify patient eligibility, it instead inappropriately paid $2 billion for home-health claims that were missing documentation between January 2011 and December 2012, according to a recent OIG report. The report said 32 percent of all home-health claims requiring the face-to-face encounter either had no documentation, or included documentation missing required information such as a physician's signature or the date of the face-to-face encounter.

Which Providers Will Have Star Power?

CMS is creating a five-star ranking system for hospitals, home health and dialysis providers. Providers are wary because the agency doesn't appear to have many details worked out yet.

Think Tank to Recommend Long-Term Care Solutions

A public policy center is tackling the difficult policy question of how to provide long-term care services to millions of aging baby boomers in the coming years without bankrupting Medicaid, which...

Compliance Comes to San Diego: Inside the Recent HCCA Compliance Institute

San Diego may be known for perfect weather and gorgeous beaches, but this past week it became the epicenter of health care compliance, courtesy of the Health Care Compliance Association's Compliance Institute. I had the opportunity to attend and also participate as a speaker as part of a Bloomberg BNA panel on how the media covers health care fraud and abuse and compliance issues.

SGR Law is a Big Win for Clinical Labs

Clinical labs and diagnostic test manufacturers scored a major victory when the SGR law updated the antiquated method Medicare pays for diagnostics with what stakeholders say is a much-needed boost of transparency.

House Budget Plan Recycles Health Care Proposals

The fiscal 2015 budget blueprint released by House Republicans April 1 again proposes to repeal the Affordable Care Act, turn Medicaid into a block grant program, and remake Medicare based on a...

Glaring Gaps Found in CMS Database of Terminated Providers

Most state Medicaid agencies would agree that accessing a comprehensive database of terminated providers is a good thing. So would CMS. Why then is the actual database (the Medicaid and Children's Health Insurance Program State Information Sharing System) so lacking in information? According to a recent  report  from the OIG, one of the chief culprits is that states are not required to submit records on terminated providers to MCSIS; instead, CMS just encourage them to.

Is ICD-10 Going to Be Delayed, Again?

I took the highway up to Charm City (aka Baltimore) yesterday for an AHLA conference, and I was a bit surprised to hear that ICD-10 might be delayed once again. Marc Hartstein, the director of CMS's Hospital and Ambulatory Policy group, said that while "ICD-10 is going forward at this particular point in time", activity on Capitol Hill might result in a further delay.

Putting the Brakes on ICD-10

For months, federal regulators have insisted the nation’s health care system would indeed move forward with implementing the massive new ICD-10 code set in October. But a bill passed March 27 in...

House Republicans Unveil Temporary Doc Fix

Chances are dwindling that Congress will pass legislation permanently fixing Medicare’s physician payment system, at least this year. House Republicans March 25 unveiled legislation to extend...

The Rarity of Health IT-Related Recalls

A recently announced Class I recall of a McKesson Corp. clinical decision support system by the Food and Drug Administration is noteworthy both for its potential impact on the health information...

Provider Groups to Congress: Hands Off Our Stark Law Exceptions

A group of 31 provider associations, including the American Medical Association and the American College of Cardiology, urged Congress not to limit the Stark law's in-office ancillary services exception (IOASE), according to a recent letter sent to the Senate Finance Committee and the House Ways & Means and Energy and Commerce Committees.

Are the Two-Midnights Policy and RACs Behind Medicare's Appeals Backlog?

Medicare is currently facing a backlog of 375,000 pending claims appeals, and the two-midnights policy and the RAC program may be a big part of the problem, according to a recent letter from Rep. Jim McDermott (D-Wash.) to HHS Secretary Kathleen Sebelius. According to the letter, "the backlog in appeals must be addressed and to effectively address the backlog, the primary drivers of potential increases in Medicare appeals must be addressed, including the two midnights policy and the [RAC] program."

Senate Doc Fix Bill Would Cost $180 Billion, CBO Says

A revised Senate bill (S. 2110) to permanently repeal and replace Medicare’s physician reimbursement system would cost $180.2 billion over the period 2014-2024, according to an estimate by the...

Fun with ICD-10

Today I'm going to take a little break from the more serious health policy issues and focus on some fun with ICD-10. I went to HCCA's first-ever regional conference in DC, and was entertained by a presentation from D. Scott Jones, a senior vice president at HPIX, a provider of physician medical professional liability insurance.

MA Program Thriving Despite ACA Cuts, MedPAC Says

Payment cuts to Medicare Advantage plans contained in the Affordable Care Act have yet to impact the health of the program, according to the Medicare Payment Advisory Commission. In its annual March ...

Overpayments Continue to Plague Medicare, OIG Finds

While outright fraud might get more headlines, overpayments due to incorrect billing continue to bedevil the Medicare program, according to three recent OIG reports. This time the culprits are three member hospitals of the CHRISTUS Health network that the OIG said  received roughly $3.3 million in Medicare overpayments between January 2010 and June 2012.

Is It OK for Third-Party Premium Assistance in the Insurance Exchanges?

Since last fall, there has been a lingering question over whether a third-party can pay premiums for individuals enrolled in health plans offered on state and federal insurance exchanges. An interim final rule that recently arrived at the Office of Management and Budget soon might help answer that question.

Is CMS Doing a Good Job Screening Providers for Fraud?

With providers eligible for significant incentive payments related to their deployment of electronic health records technology, it's crucial that screening procedures are in place that can detect fraud and stop payments.

Bicameral Doc Fix Bill Would Cost $138B, CBO says

The Congressional Budget Office said Feb. 27 that bicameral, bipartisan legislation (S. 2000, H.R. 4015) to repeal and replace the Sustainable Growth Rate formula of Medicare’s physician payment...

Government Rakes in $4.3 Billion from Anti-Fraud Efforts

Fiscal year 2013 was a banner year for the federal government, with anti-fraud efforts resulting in $4.3 billion in recoveries, according to the recent Health Care Fraud and Abuse Control (HCFAC) program report.

Physicians and Hospitals Urge HHS to Slow Down on Meaningful Use

A coalition of 48 provider organizations, including the American Medical Association and American Hospital Association, recently urged HHS to delay deadlines for Stages 1 and 2 of the electronic health record meaningful use program through 2015.

CMS Calls Timeout on RAC Document Requests

In a move sure to please providers, CMS has pushed the pause button on the RAC program, suspending additional documentation requests (ADRs) until it completes the procurement process for new RAC contracts.

Congress to CMS: Time to Fix the RAC Program

The Recovery Auditor Contractor program has been a magnet for criticism since it became operational in 2005, and a bipartisan group of 111 congressmen has recently joined the party. In a  letter  to HHS Secretary Kathleen Sebelius, the congressmen called for stronger program oversight as well as a reduction in the backlog of pending RAC appeals.


Patient Advocates Celebrate Five Years of HITECH

Five years after the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law, one patient advocacy organization said health IT tools have become essential...

Personalizing the Treatment of Cancer

A panel discussion at a conference I covered Feb. 14 provided intriguing insights about personalized medicine’s promise for treating cancer. Like so many others, I had a loved one who painfully but...

AHRQ Pushing for Health IT Safety Research

The Agency for Healthcare Research and Quality says it will use some of the $4 million it has appropriated for health IT research this year to support projects that examine the “high impact”...

Is Change Coming to the 340B Program?

It looks like change might be in the wind for the 340B drug pricing program, after a recent OIG report found inconsistencies in how program participants determine if individuals qualify for the...

OIG Work Plan Includes Focus on Insurance Exchanges

At long last, the OIG's fiscal year 2014 work plan is out, and the state and federal insurance exchanges can expect some special attention over the next few months. The OIG said it will review...

The Right Attitude for EHR Adoption

How much can a clinician’s gender and attitude dictate how easily they will adopt new health information technologies? A lot, according to a study published in the January edition of the...

Personalized Medicine Extends into Wellness

The promise of personalized medicine has prompted life sciences companies and medical researchers to continue to pursue the next logical step—into wellness. Personalized medicine is usually defined...

Obama’s State of the Union Health Care Remarks

While President Barack Obama staunchly supported the Affordable Care Act in his State of the Union address Jan. 28, ACA opponents noted that he didn't get to his signature 2010 law until more than...

Medicare Strike Force Operating on All Cylinders

Fiscal year 2013 was a record year for the Medicare Fraud Strike Force program, which continues to put a dent in fraud eight years after its inception. According to a recent release from the...

Courts Strive to Balance Competing Interests

A recent order on attorneys’ motion to withdraw in a patent infringement case involving a cancer treatment system highlighted for me the challenge courts face in balancing competing interests. In ...

How High Are ACO Startup Costs?

According to a new survey, ACOs participating in the first year of the MSSP had average startup costs of $2 million.

House Doc Fix Bill Would Cost $121 Billion, CBO Says

The Congressional Budget Office Jan. 24 estimated the cost of a House Ways and Means Committee proposal to overhaul the Medicare physician payment formula at $121 billion over 10 years. The...

CBO Names Health Advisors

The Congressional Budget Office has released the names of 22 stakeholders that will sit on its panel of health advisors for 2014, a group the CBO expects will provide information on the latest...

Is Medicare Paying too Much for Impotence Devices?

Medicare is paying twice as much for male impotence devices compared to private consumers and the Department of Veterans Affairs, according to a recent report from the HHS Inspector General, and...

HHS Releases Marketplace Demographics

For the time first time, the Department of Health and Human Services released demographic information Jan. 13 on the 2.2 million people who enrolled in health care coverage through the Affordable...

CMS To Release Medicare Physician Payment Data

The Centers for Medicare & Medicaid Services said Jan. 14 it will consider requests from the public for information on how much money doctors make treating Medicare patients. The CMS said in a...

Are MACs Up to Snuff When It Comes to Quality?

When it comes to quality control, Medicare Administrative Contractors still have work to do, according to a recent report from the OIG. According to the report, MACs didn't meet 26 percent, or 310,...

Top Health Insurance Issues for 2014

Many of the issues that made headlines in 2013 will continue into 2014, Health Insurance Report advisory board members said in assessing key issues for the new  year.  Those include health...

Patients Want Doctors with E-mail

While the proportion of health-care providers who have adopted electronic health records grew significantly over the past two years, the percentage of providers electronically communicating with...

OIG to Review Troubled Rollout of

Investigators at the HHS Inspector General will soon be turning their attention to the flawed rollout of the website, pursuant to a request from HHS Secretary Kathleen Sebelius. In...

CBO Lowers Cost of Medicare Physician Pay Fix

The Congressional Budget Office has lowered the cost of permanently fixing Medicare’s physician payment system, which could add momentum to congressional efforts to replace the Sustainable Growth...

House, Senate SGR Markups Possible Next Week

Next week is likely to be one of the busiest weeks in quite a while in Congress on a health care issue that does not directly involve the Affordable Care Act. The Senate Finance Committee Dec. 12...

Should Private Health Care Pay Before Medicaid?

If an individual is covered under both Medicaid and a private health plan, who pays for health care? If you said the private health plan, give yourself a pat on the back. This concept recently...

Notes from Orlando's NHCAA Conference

Ask anyone about Orlando and chances are they'll tell you it's the Magic Kingdom. That may be true, but last week Orlando transformed into an epicenter of the fight against health care fraud as the...

Is There a Problem with Medicare Outlier Payments?

Can Medicare outlier payments be too high? Maybe so, according to a recent report from the OIG. The report found that 158 hospitals qualified as high-outlier hospitals, meaning outlier payments...

Is Anyone Minding the Store at SAMHSA?

Protecting private information should be ingrained in federal government agencies, but apparently the Substance Abuse and Mental Health Services Administration (SAMHSA) didn't get the memo. A...

Medicare Doc Fix Unlikely In 2013, Attorney Says

Legislation signed by President Obama reopening the federal government and extending its borrowing authority is likely to delay congressional action on a Medicare physician pay fix until 2014,...

Is OIG Infringing on First Amendment Rights?

Infringing someone's First Amendment right is a pretty big deal, especially when it's the government allegedly doing it. That's the crux of a recent lawsuit filed by a Utah-based medical device...

Medicare Appeal Success Rates Trending Down

If you're thinking of appealing a denied Medicare claim, you might want to ready yourself for some disappointment, especially if it's a Medicare Part A claim. Only 24 percent of appealed Medicare...

Stark Self-Disclosures Are on the Rise

I blogged yesterday about the rise in provider self-disclosures related to overpayments, and for today's installment we're going to turn to the corresponding increase in provider Stark law...

Providers Increasingly Self-Disclosing Overpayments

\ Voluntary self-disclosures of overpayments are up as providers look to avoid government action, a DOJ official said at a conference I attended Monday. Margaret Hutchinson, chief of the civil...

CMS Approves Arkansas Medicaid Expansion Plan

The Centers for Medicare & Medicaid Services Sept. 27 approved an unusual Medicaid expansion proposal request from Arkansas that will allow the state to provide coverage for new enrollees via...

Get Ready to Say Hello to a New RAC

Medicare Advantage plans will soon be introduced to their new RAC, a CMS official said at the AHIP Medicare conference I attended this week. Sonja Brown, a CMS health insurance specialist, said the...

Prescription Drug Spending Falls In 2012, CMS says

You won’t see this happen too often in the world of health care, but spending on a health care sector—in this case prescription drugs--actually fell in 2012 . In its annual report on national health...

Is Trouble Brewing for the Navigator Program?

Are you looking for help enrolling in the new health insurance marketplaces? Well, a program designed to do just that may be prone to fraud and abuse, according to a report from the House...

Medical ID Theft Could Cost You $19,000

Keep a close watch on your personal medical records, because if they get stolen, you could be on the hook for $19,000, a recent survey  said. The Ponemon Institute survey said 36 percent of...

Could Medicare Part B Rebates Really Save Billions?

If Medicare could save $3 billion, wouldn't that be a big deal? According to a recent report from the OIG, Medicare could have saved as much as $3.1 billion in 2011 by requiring pharmaceutical...

CMS Loses Program Integrity Director

After three-plus years in charge of program integrity efforts for Medicare and Medicaid, Peter Budetti is retiring. An internal e-mail from CMS Administrator Marilyn Tavenner said Budetti's last...

Are Medicare Contractor Reviews Too Confusing?

Differing standards and requirements among four Medicare program integrity contractors are leading to some major headaches for providers and reducing the overall efficiency of postpayment claims...

Illinois Toughens Up Medicaid Fraud Penalties

If you're thinking about committing Medicaid fraud in Illinois, you might want to think again. Thanks to newly signed legislation (Public Act 098-0354), the Illinois Department of Healthcare and...

HHS Release New Health IT Implementation Strategy

The Department of Health and Human Services is ramping up efforts to help expand the use of health care information technology among providers. HHS Aug. 7 released a new comprehensive health care...

Mid-Sized Companies Face Greatest Challenges Under ACA

Mid-sized companies that are subject to the Affordable Care Act’s large “shared responsibility” payments face the greatest challenges, Senate Small Business Committee Chairman Mary Landrieu (D-La.)...

House Panel Approves Medicare Physician Pay Fix

Congress July 23 took another step toward eliminating Medicare's current physician payment system when the House Energy and Commerce Health Subcommittee approved draft legislation that would repeal...

Obama Highlights Affordable Care Act Refunds

President Obama used the disbursement of $500 million in "medical loss ratio" (MLR) refunds to show that the Affordable Care Act "is working the way it was supposed to for middle-class Americans" at...

Provider Self-Disclosure Takes to the Web

With the click of a mouse, physicians and other types of providers will now be able to self-disclose potential fraud, thanks to OIG's July 8 launch of an online self-disclosure form . The new form...

An Alzheimer's Ruling Too Long for its Own Good?

Can a court decision about an Alzheimer’s disease patent owned by an important U.S. biopharma company be virtually ignored because it is too long? The answer is yes, attorneys told me. On June...

Is ICD-10 Implementation Too Expensive?

Physicians are concerned that the upcoming transition to ICD-10  is going to be too expensive, according to a June 13  study from the Medical Group Management Association. 95 percent...

Medciare Margins Of SNFs, HHAs, Come Under Fire

The double-digit Medicare profit margins of skilled nursing facilities and home health agencies came under fire from three directions June 14, indicating program payments to the sectors could be...

OIG Spotlights Elevated Costs for Medicare Lab Tests

An OIG report said Medicare could have saved $910 million in 2011 if clinical lab test payment rates had been reduced to the levels paid by Medicaid and Federal Employees Health Benefits (FEHB)...

Health Insurers Call Insurance Fee Double Taxation

A proposed regulation implementing a $101 billion health insurance fee imposed by the Affordable Care Act amounts to double taxation, health insurers told the Internal Revenue Service (IRS) in...

Bipartisan Bill Looks to Toughen Up Fraud Penalties

A bipartisan bill introduced June 10 in the Senate and House would strengthen penalties for medical identity theft and penalize Medicare and Medicaid contractors for excessive error and...

Biopharmas Still Worry ACA Will Hurt Drug Development

As the Affordable Care Act moves closer to being fully implemented, the concern among biopharmas that ACA will adversely affect the industry continues. At the “Affordable Care Act Is Here to Stay”...

Will Sunshine Act Put a Freeze on Health Care R&D?

Speakers at a webinar I attended this week said the Sunshine Act might chill legitimate R&D activities carried about by physicians and teaching hospitals. Meenakshi Datta, an attorney with...

Senate On Verge of Approving Tavenner Nomination

Barring an unforseen twist, the Centers for Medicare & Medicaid Services is about to have its first Senate-confirmed administrator since 2006. The Senate the week of May 13 is expected to vote...

Are Medicare Fraud Tipsters in Line for a Big Payday?

Medicare fraud tipsters may soon be rolling in the money, thanks to a recent HHS proposed rule that would increase reward money for a successful tip from a maximum of $1,000 all the way up to $9.9...

New ACO-type Models Highlighted In Reform Reports

It may be awhile before policymakers know if Accountable Care Organizations will fulfill their promise of lowering the cost of health care while improving outcomes, but experts have recently...

Are OIG Provider Compliance Reviews Coming Soon?

I spent the first part of this week at HCCA's Compliance Institute, and while there, I heard Inspector General Levinson suggest that OIG might be interested in performing compliance reviews on...

OIG Takes Another Crack at Self-Disclosure Protocol

I spoke with OIG's Tony Maida this week about their recently revised self-disclosure protocol , and he told me the idea behind the revision was to increase transparency for providers. He told me...

Say Goodbye to the HIPDB

It's official: the Healthcare Integrity and Protection Data Bank will soon be no more. HRSA, in an effort to reduce regulatory burden, recently issued a final rule that will result in the transfer...

Stark Law Self-Disclosure Proving to Be Very Popular

Providers have embraced CMS's Stark law disclosure process, a CMS official said at a conference I attended this week. Troy Barsky, the director of CMS's Division of Technical Payment Policy, said...

OIG Updates Guidance for State False Claims Act Laws

For the first time ever, OIG has updated the guidelines for evaluating state false claims act laws, taking into account amendments made to the federal false claims act in 2009 and 2010. Under the...

Sequester May Take a Bite Out of Anti-Fraud Programs

It's still early days, and no one really knows what impact the sequester cuts will have on the economy, but I recently talked to a few health care experts who all agreed that the cuts have the...

CMS To Conduct Audits on EHR Use, Tavenner Says

The Centers for Medicare & Medicaid Services remains committed to ensuring Medicare providers adopt electronic health records, despite an increase in claims upcoding that may be related to the...

Once Again, CMS Leaving Money on the Table

In what's by now a familiar story, a recent report from the OIG discovered that CMS has failed to collect $225 million in state Medicaid overpayments. Between fiscal years 2000 and 2009, the OIG...

Is CMS Trying to Verify the Unverifiable?

I recently heard CMS's Peter Budetti speaking at the National HIPAA Conference, and he said CMS is working with other government agencies to create a methodology for calculating the value of cost...

Baucus to Hold Nomination Hearing for Tavenner

Senate Finance Committee Chairman Max Baucus plans to hold a confirmation hearing on the nomination of Marilyn Tavenner to be administrator of the Centers for Medicare & Medicaid Services. CMS...

Medicare, Still Risky After All These Years

To no one's surprise, the Medicare program has once again been found to be especially vulnerable to fraud, waste, and abuse. The GAO has designated Medicare as a high-risk program dating back to...

A Soybean Seed Case That Matters to Life Sciences

What does a Supreme Court case about the sale of soybean seeds have to do with life sciences? A lot, says the U.S. Solicitor General and life sciences attorneys. Bowman v. Monsanto ...

Orphan Drugs Receive More Regulatory Attention in U.S. and Canada

Orphan drugs are called that because the biopharma industry is said to have little interest in developing and marketing drugs that are intended for only a small number of patients suffering from very rare conditions. And yet 40 percent of FDA-approved drugs in 2012 were orphan drugs, and there are plans for consideration of a regulatory orphan drug framework in Canada in 2013.

CMS Faces Questions Over Predictive Modeling Report

CMS recently released a long-delayed report on the first year results of its predictive modeling program, and while the report includes some positive results, questions remain over the accuracy of...

Is CMS Sending a Mixed Message on EHRs?

While CMS is actively encouraging the use of EHRs through the meaningful use incentive program, it may be sending a mixed message courtesy of a recent transmittal. Effective Dec. 10, the transmittal...

HHS Releases Three Proposals to Implement ACA

The torrent of regulations to implement the major provisions of the Affordable Care Act began in earnest Nov. 20 when the Department of Health and Human Services issued two proposed rules and...

House Republicans Subpoena MA Demo Documents

The House Oversight and Government Reform Committee Oct. 22 sent a subpoena to the Department of Health and Human Services for documents related to the creation of a Medicare managed care...

OIG Reviews of Electronic Health Records on the Rise

EHR users, beware: the OIG is looking at you. The coming year should see an increase in OIG reviews of EHR use, according to an HCCA webinar I attended this week. Specifically, the OIG will be...

When In Doubt, Self-Disclose

With providers facing increasing penalties for Medicare and Medicaid program violations, self-disclosure is on the rise, an OIG official said at a recent conference I attended. Tony R. Maida, a...

Power Wheelchairs On the Congressional Hot Seat

. We've all seen the television ads for scooters and power wheelchairs, the ones that promise seniors they can get a chair for free. Well, so has Congress, and they're not too pleased about...

Medicare Part D RACs Finished With 2007 Audits

Medicare Part D RACs have finished their audits for the 2007 contract year, a CMS official said during a webinar I attended last week, the latest evidence of the spread of the RAC model from its...

OIG Continuing to Uncover Medicare Overpayments

Provider overpayments are plaguing the Medicare program, as two recent OIG reports illustrate. According to one report, a Medicare contractor made $2.2 million in provider overpayments between 2006...

Ryan Choice As VP Heightens Focus on Medicare

The choice by presumptive Republican presidential candiate Mitt Romney of Rep. Paul Ryan (R-Wis.) as his vice presidential running mate ensures a full-throttle debate on the future of Medicare likely...

House Committee Debates Federal Exchange Subsidies

Health reform law critics and supporters faced off against each other Aug. 2 in a debate over whether the law allows exchange markets that will likely be set up in most states by the federal...

FDA Approves Ingestible Sensor

Despite the best intentions of doctors, patients are not always the best at remembering to take their medications. But a new device recently approved by FDA aims to make it easier for doctors to see...

Has CMS Dropped the Ball on Outlier Payments?

CMS failed to reconcile outlier payments contained in a majority of hospital cost reports from 2003 through 2008, resulting in less money going into the Medicare Trust Fund and putting some...

New, and Dangerous, Twist in Health Care Fraud

Americans have long had confidence in their pharmacies to dispense brand-new, and safe, prescription drugs. That confidence has suffered a blow, courtesy of a fraud scheme that was recently...

Twelve States Notify HHS They Will Establish Exchanges

Twelve states have notified the Department of Health and Human Services that they intend to establish their own internet-based health insurance exchange markets in accordance with the health care reform law, HHS Secretary Sebelius announced July 11.


Not Quite Full Speed Ahead

Despite CMS moving forward with delivery reform initiatives, providers still don't know which model will work the best.

EHR Systems on the Rise Among Medicare Physicians

Electronic health records got a boost from Medicare physicians in 2011, with 57 percent reporting that they used an EHR system in their primary practice location. The results were included in a...

OIG Says It's Time to Update Provider Self-Disclosures

The OIG is getting set to update the provider self-disclosure protocol, and it's looking for help from the public. The June 18 Federal Register featured a notice from the OIG asking for recommendations on how best to revise the protocol, which was originally published by the OIG in 1998.


Medicaid Audit Program Faces the Music

Senators were less than pleased with the results of Medicaid’s national audit program, during a subcommittee  hearing I attended this week. The GAO said Medicaid program integrity contractors...

Health Care Reform With or Without PPACA

May 22 Bloomberg held a seminar in New York on health care reforms that will continue no matter what the Supreme Court decides about the constitutionality of the Patient Protection and Affordable Care Act.

OIG Worried CMS Is Leaving Money on the Table

CMS contractors are failing to recover the vast majority of all Medicare overpayments, and the OIG says something’s got to give. One area ripe for improvement is the Audit Tracking and Reporting System (ATARS), which contractors use to record the status of overpayment collections.