Is HHS Doing All it Can to Reduce Improper Payments

Improper payments are the scourge of Medicare, and the federal government has made numerous efforts to crack down on them.

Does Obamacare Need a Special Inspector General?

The Obama administration has taken such great liberties in implementing the Affordable Care Act that a special inspector general is needed just to oversee the law, the chairman of a House Ways and Means subcommittee argued May 20.

CMS Set to Release Medicaid Managed Care “Uber Rule”

The CMS is poised to release in the coming weeks what stakeholders and advocates are calling an “uber rule” that will completely overhaul the Medicaid managed care marketplace. Agency officials haven’t offered much specific information about what may be included in the proposal, or even when it will be released—although it’s been under regulatory review at the OMB since March, and the agency has been working on the regulations for over a year.

Is HHS Properly Assessing Medicaid Expenditures?

Determining whether federal Medicaid expenditures are fully justified is a core responsibility of the Department of Health and Human Services, but its oversight might be lacking, according to a recent report from the GAO.

‘Ironic’ TV Episode Highlights Medical Research’s Twists and Turns

A British television series last night briefly but tellingly highlighted the sometimes tragic twists and turns of medical research.

States Have Vital Role in Biosimilars and Are Stepping Up

While the recent first approval of a biosimilar in the U.S. attracted the most attention, there has also been a recent stream of state laws that are essential to the biosimilar process.

Even With Individual Coverage, Health Care Still Unaffordable for Some

The Affordable Care Act has succeeded in lowering the rate of uninsured people in the United States, but more than a quarter of adults with nongroup coverage in 2014 still went without needed care because they couldn’t afford it, according to a study released May 14 from a health-care consumer group.

Health Plans Poised To Ask for Higher Premiums for 2016, Blue Cross Executive Warns

Look for health plans to request higher rates for 2016, a Blue Cross and Blue Shield Association (BCBSA)  executive warned May 13.

Who’s Behind the Lack of Telehealth Reforms in Cures Bill?

The American Telemedicine Association’s chief executive officer, Jonathan Linkous, told me May 13 the Centers for Medicare and Medicaid Services and the Congressional Budget Office likely curtailed lawmakers’ efforts to expand Medicare reimbursement for telehealth services.

Did Place of Service Errors Cause $33.4 Million in Medicare Overpayments?

It may be a bit of a cliché, but location really does matter, and when that location happens to be where a medical procedure was performed, errors can lead to millions in Medicare overpayments. A recent report from the OIG said Medicare potentially overpaid physicians by $33.4 million between January 2010 and September 2012 due to errors made while coding for a procedure’s place of service.

CEO of Federal ACA Exchange: Does Offer Too Much Choice?

Does the federal government’s insurance exchange offer too much choice? Its chief executive officer hinted that may be the case.

Is Trouble Looming for ICD-10?

We might be entering into the hot months of summer, but before you know it it’ll be fall, and with it will come the long anticipated transition to ICD-10. However, a recent bill in the House is trying to stop ICD-10 in its tracks. H.R. 2126, formally known as the Cutting Costly Codes Act of 2015, would prohibit switching to ICD-10 from the current ICD-9 codeset. The bill, introduced by Rep. Ted Poe (R-Texas) and co-sponsored by six fellow Republicans, was referred to the House Energy and Commerce and Ways and Means committees.

Rural Providers Charge Feds Are Hampering Ability to Get Quicker Internet Access

The federal government’s effort to expand broadband access for health-care providers around the country hasn't helped those most in need of faster Internet access and hospital groups are calling major reforms.

Rule Delay Would Create Headaches For Labs, Trade Group Says

The Centers for Medicare & Medicaid Services will likely miss a June 30 deadline for issuing a rule about how it will collect market data and set new rates for Medicare payment of clinical labs, agency official Marc Hartstein told attendees of the American Clinical Laboratory Association's (ACLA) annual conference May 5.

RAND Finds Big Jump in Insured Since ACA Started; More Buying Employer-Sponsored Insurance

While it’s difficult to know with certainty how many people have gained health insurance coverage because of the Affordable Care Act, a study by the RAND Corp. estimated that 16.9 million people have joined the ranks of the insured since the law took effect.

Are Generic Drugs Getting Enough Oversight?

The quality and safety of pharmaceutical drugs is always a concern, and as generic drugs have proliferated in the market, it has become even bigger. The OIG recently issued a report on FDA oversight of the generic drug industry, prompted by a request from Congress. The request followed the $500 million settlement India-based drug manufacturers Ranbaxy reached in 2013 over allegations of substandard generic drugs.

Health Care Data Not Safe From Thieves, Report Finds

The data storage and analysis companies that are managing the growing stores of patient data for health-care organizations aren’t keeping information safe from data thieves, researchers said recently.
Nearly 60 percent of the companies that handle patient health information for a health-care organization had at least one data breach involving the loss or theft of patient data in 2013 and 2014, according to a study by the Ponemon Institute. The study is one of the first to examine breaches by the groups that handle data for health-care organizations. Fifteen percent of data holders said they had more than five breaches during that time.

Nearly 7 Million Small Business Enrollees Could Lose Coverage If Supreme Court Overturns ACA Rule

Small businesses typically are charged higher prices for health insurance than large companies, and as a result they’re less likely to offer the benefit to their employees.

Do We Have to Do the Biosimilar Patent Dance?

Do biologic developers and biosimilar applicants  have to do the patent dance?, panelists asked at a recent biotech conference.

H&R Block: Two-thirds Who Received 2014 ACA Subsidies Had to Repay Some

People who receive subsidies to help pay for health insurance bought through the Affordable Care Act marketplaces need to learn to be more conservative in estimating their income. That is the chief lesson learned following 2014, which was the first year the marketplaces, subsidies and penalties for not having insurance took effect under the health-care law.

What Device-Related Provisions Could Be Added to Future Cures Bills?

The latest draft of a House proposal intended to spur development of new drugs and devices needs more work on some information technology issues, the FDA’s Jeffrey Shuren told a medical device conference April 30.

Are State Insurance Exchanges Misspending Federal Funds?

Federal funding usually comes with certain restrictions, and that is certainly the case with the federal establishment grants, which were provided to states solely for the development of their insurance exchanges under the ACA.

Docs Losing Medicare Dollars for Ignoring Federal Health IT, Quality Reporting Programs

The federal government this year is expected to pay about $350 million less in Medicare reimbursements to doctors that haven’t been participating in various health IT and quality reporting programs, according to data from the Centers for Medicare & Medicaid Services.

Can the Medicare Appeals Backlog Actually Get Fixed?

It’s no secret that there’s a big problem with the Medicare appeals process, what with over 500,000 appeals currently pending a resolution and an average processing time of 547 for claims appeals in FY 2015. But hope springs eternal, and a recent Senate Finance Committee provided some clues as to what fixing the appeals process might entail.

Fewer, Better Targeted Health Care Outcomes Measures Needed, IOM Says

There are hundreds of quality measures in use that track health care quality, but the Institute of Medicine says many overlap or are redundant and thus it has proposed a core set of 15 measures focusing on those that will have the “greatest potential to positively affect the health and well-being of Americans.”

What If You Have to Eat a Forest?: New Arguments to Patent New Antibiotic

An attorney is trying again to patent a new antibiotic and has unearthed an exchange in Supreme Court oral arguments to support her efforts.

Federal Government Will Re-Calculate ACA Subsidies for Automatic Renewals for 2016

People who don’t return to the Affordable Care Act marketplaces to update their eligibility information for premium tax credits will be automatically re-enrolled for 2016, and – for the first time -- the federal government will recalculate their subsidies.

Republican Leader Vows Alternative Plan Will Be Ready Before Supreme Court ACA Subsidy Ruling

Republicans “will be ready to act with legislation” when the U.S. Supreme court hands down a decision on whether subsidies can go to enrollees in 34 states where the federal government operates health insurance exchanges under the Affordable Care Act (ACA), the chairman of a congressional health subcommittee pledged April 23.

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.

How Are Stakeholders Reacting Plans to Bundle Post-Acute Care Payments?

Different providers and their trade associations told a House subcommittee hearing April 16 that they support bundling Medicare payments for post-acute care (PAC) services.

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.

At Long Last, 5-Star Ratings Hit the Hospital World

We already rate everything from movies to books to music, so why not add hospitals to the mix.

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.

Is the FDA Planning to Hold More Device Advisory Panel Meetings?

A new FDA draft guidance may signal that the agency will begin to hold more advisory panel meetings on different kind of industry applications for devices, an attorney told me April 10.

Obamacare’s Exchange Outperformed State Exchanges for 2015, Analysis Finds

When the Affordable Care Act health insurance exchange set up by the U.S. Department of Health and Human Services could barely function during the first two months of open enrollment in the fall of 2013, many observers thought that most of the states that had created their own exchanges did a better job.

What Do Stakeholders Think of FDA’s Latest Effort to Get Patients Timelier Access to Devices?

The FDA April 8 released two final guidance documents that will help provide timely patient access to high-quality, safe and effective medical devices for unmet medical needs, Jeffrey Shuren, the director of the agency's Center for Devices and Radiological Health, said in a blog posting.


How Can Electronic Drug Alert Programs Improve Patient Safety in ACOs?

A new study found that electronic drug alert programs can play an important role in ensuring optimal prescription use and improving patient safety in accountable care organizations.

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.

Medicare Punished Aetna For Network Pharmacy Errors

When you head to one of your health plan’s network pharmacies, you expect nothing out of the ordinary: you’ll present your prescription, get your medicine, and be on your way.

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. 

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.

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.

Only 36,000 Signed Up for ACA Coverage During Tax Special Enrollment, HHS Reports

Affordable Care Act proponents have argued that when people who remained uninsured in 2014 realize they must make a “shared responsibility” payment when they file their tax returns, it will be a so-called teachable moment and many will want to sign up.

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.

Mental Health Group Report Finds Problems With Health Insurance Coverage

Health insurers have been criticized for offering “narrow networks” of providers in plans sold in the Affordable Care Act (ACA) marketplaces.

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.


What Will Happen to Medicare’s Hospital Inpatient Rates in 2016?

The 2016 payment increase for hospitals paid under Medicare's inpatient prospective payment system may be slightly less than the one the CMS approved in 2015, a health-care attorney said March 26.

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.

Congress Upset About Lack of Anti-Fraud Results, Again

It may sound like a broken record, but Congress is once again upset over the lack of results from federal anti-fraud programs.

EHR Certifiers Don’t Want to Test EHR Performance in Doctor’s Offices

Groups certifying electronic health record systems in the $29 billion federal meaningful use program are pushing back against an ONC proposal to test the performance of EHRs at doctor's offices and hospitals.

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.

Cybersecurity, Disaster Preparedness, G.W. Bush to Highlight HIMSS15 Conference

This year the health information technology industry’s largest conference will include dedicated forums on cybersecurity and disaster preparedness, reflecting a few of the major health IT headlines from the past year, as well as a keynote address by former President George W. Bush.

Why Biopharmas Are Watching ‘Patent Troll’ Legislation

Biopharmaceutical companies are closely watching bills in Congress that are meant to curb “patent trolls,” even though biopharmas don’t yet have a dog in that fight.

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.

CMS is Watching How Hospitals Use Blood Glucose Monitoring Systems

The Centers for Medicare & Medicaid Services recently pulled a November 2014 memorandum about off label use of blood glucose monitoring systems and is seeking comments on the revisions. 

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.

16.4 Million Gain Health Insurance Since Obamacare Expansion Began, HHS Says

The Obama administration says 16.4 million adults have gained health insurance since the Affordable Care Act’s coverage expansion began, and it said a 7.1 percentage point drop in the uninsured rate is primarily driven by the health law enacted in 2010.

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.

Medicare Could Save Billions, If Only It Listened to the OIG

Not all recommendations are heeded, a fact of life for everyone, even the government. As proof of this point, the OIG recently issued the rather arcane sounding Compendium of Unimplemented Recommendations.

CMS Attempts to Address Provider Concerns by Unveiling New ACO Model

The CMS is attempting to make Medicare ACOs more attractive to providers by unveiling a new model in which providers will assume greater risk while also potentially sharing in more savings.

Last Chance for Tax Filers to Avoid ACA Penalties

People who discover they owe a penalty for not having health insurance in 2014 as required by the Affordable Care Act have one last chance to get coverage for 2015.

What’s the FDA Doing to Counter Infection Risks from Reusable Devices?

The Food and Drug Administration took two steps March 12 to show it’s working to reduce the risk of infection from reusable medical devices.

Where Have All the Laptops Gone? Home-Health Provider Reports 142 Missing Laptops

No one wants to lose their laptop, especially since we keep so much of our life inside them these days: pictures, videos, music, credit card info.

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.

Faced With Stormy Regulatory Seas, Industry Calls for More Safe Harbors

In today’s regulatory climate, a safe harbor is more important than ever, and health-care stakeholders haven’t been shy about voicing their support for increased protections from the anti-kickback statute.

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).

Republicans Want to Extend CHIP. So Why Are Advocates Worried?

House and Senate Republicans recently released a draft plan to extend funding for the Children's Health Insurance Program.

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.

Little-Noticed ACA Provision Could Impact Small Group Plans in 2016

A little-noticed provision in the Affordable Care Act could have a big impact on companies with 100 workers or less in 2016.

ONC Again Mulls Strengthening Oversight of Health Information Exchange

Federal regulators are again considering taking a more active role in governing the electronic exchange of health information between health-care providers, the director of the Office of the National Coordinator for Health IT’s Office of Policy recently told me.

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.

No Long-Term SGR Solution Forthcoming, But Could it Link to CHIP?

Any hopes-- however remote-- of Congress passing a permanent repeal of Medicare's sustainable growth formula by March 31 were doused at the recent advocacy meeting of the American Medical Association.

Will Social Security Numbers Finally Be Banished From Medicare Cards?

Over the past several years, there’s been much talk in Congress about removing Social Security numbers from Medicare beneficiary cards, but no action.

Many ACA Enrollees Still Getting Incorrect Subsidies, House Member Says

Tax preparer H&R Block Inc. reports that 52 percent of its clients who received Affordable Care Act subsidies to buy health insurance are having to repay at least a portion of them, with the average repayment $530, reducing their refunds by about 17 percent.

CMS Extends Meaningful Use Attestation Deadline, Citing Concerns from Providers

The deadline for health-care providers to attest to meeting the requirements of the Medicare and Medicaid Electronic Health Record Incentive Program in 2014 has been extended to March 20, the Centers for Medicare & Medicaid Services announced recently.

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.

No Plan in Place Should Supreme Court Strike Down ACA Subsidies, Burwell Says

HHS Secretary Sylvia Mathews Burwell told Congress Feb. 24 the administration has no contingency plan should the U.S. Supreme Court rule insurance subsidies under the Affordable Care Act are available only in the states that have set up their own health-insurance exchanges.

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.

PTO, Former Patent Commissioner Say Eligibility Guidance Improved for Life Sciences

The PTO’s interim guidance on patent eligibility isn’t perfect, but it’s better, participants at a Jan 20 forum said.

HHS Allows Special ACA Enrollment Period; Will Send New Tax Forms to 800,000 People

The Centers for Medicare & Medicaid Services on Feb. 20 announced a special enrollment period for people who didn’t have health coverage in 2014 as required by the Affordable Care Act and who are subject to a fine when they filed their 2014 tax returns.


Life Sciences Attorney at PTO Forum Still Asks for Patent Eligibility Guidance Revisions

Most of those speaking on behalf of the life sciences community about claims for a natural based product continued to express concerns about the Patent and Trademark Office’s guidance on patent eligibility.

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.

HHS Secretary Burwell Says Goal of 9.1 Million Paid ACA Enrollees Likely to be Met

In November 2014 the Department of Health and Human Services announced a goal of enrolling 9 million to 9.9 million paid consumers in the Affordable Care Act health insurance marketplaces for 2015, a reduction from a Congressional Budget Office projection earlier that year of 13 million.

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.

Myriad Genetics—On the Wrong Side of a Legal Earthquake?

Myriad Genetics’ decision to step back from enforcement of its patents covering breast cancer screening lead one to ask, what will be the company and its litigations’ place in history?

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.

What Policy Changes Are Needed to Spur Medical Technology Innovation?

The Advanced Medical Technology Association, a medical device industry trade group, Feb. 10 unveiled what it thinks Congress and the administration should do to spur innovation in the medical technology field.

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.

Red and Blue States May Embrace ACA `Innovation Waivers,’ Health Care Followers Predict

The Affordable Care Act has been immensely controversial, but a provision that takes effect in 2017 may be embraced by both red and blue states. That was the consensus of health care policy followers, including supporters and critics of the law, who spoke on a panel Feb. 6.

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.

Lab Director Tells FDA on LDT Oversight: Don’t Throw Out the Baby

One lab director wrote the FDA in comments about its expanding its oversight of laboratory-developed tests, saying, basically, go after those whose tests have little clinical validation and not those of us who are offering clinically useful tests.

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.

9.9 Million ACA Sign-Ups Through Jan. 30, HHS Secretary Burwell Announces

With the second Affordable Care Act open enrollment period for marketplace coverage set to end Feb. 15, at least 9.9 million people signed up as of Jan. 30, Department of Health and Human Services Secretary Sylvia Mathews Burwell announced Feb. 4.

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.

ONC to Award $35 Million in Grants to Advance Interoperability of Health IT

The Office of the National Coordinator for Health Information Technology will award more than $35 million in grants to kick off its 10-year effort to improve the interoperability of health IT systems, the agency announced.

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.

Up to 6 Million May Owe ACA Penalties, Treasury Official Says

Between 3 million and 6 million taxpayers are expected to pay a penalty for not having health insurance in 2014 in accordance with the Affordable Care Act, a Treasury Department official said Jan. 28.

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.”

CMS Touts Promise of Two Primary Care Initiatives

Based on first year results, the CMS says its two advanced primary care initiatives show promise for saving money and improving health-care quality.

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.

Did CMS Adequately Collaborate With Stakeholders Before Launching Dialysis Star Ratings?

2015-01-22 At least two groups representing the dialysis community don’t seem to think so. Kidney Care Partners (KCP), which represents patient advocates, dialysis professionals, care providers and product manufacturers, and Dialysis Patient Citizens, an advocacy group for people needing dialysis treatment, separa

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.

How Would Site-Neutral Payments Affect Providers and Beneficiaries?

Getting a clear answer on how providers and beneficiaries would fare under site-neutral payments for some conditions at skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) is difficult to get.

Are the Phase Two HIPAA Compliance Audits Here Yet?

It’s been almost three years since the end of phase one HIPAA compliance audits, and we’re still waiting for the start-up of phase two.

Are Hospices Seeking Financial Gain by Targeting Medicare Patients in Assisted Living Facilities?

The CMS should take several steps to reform Medicare payments to hospices, including reducing financial incentives for hospices to target beneficiaries with certain diagnoses and those likely to have long stays, such as those in assisted living facilities, the Department of Health and Human Services Office of Inspector General says.

Patent Reform Proceedings Could Create Troll Problems

The Inter partes review process of the patent reform legislation is likely here for good but biopharmas and universities are finding that it is not always good for them.

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.

Hospital Participation in Meaningful Use in 2014 Nearly Hit Previous Year's Level

Nearly 4,100 hospitals attested to meeting the requirements of the meaningful use program in 2014, nearly as many as attested in 2013, according to Centers for Medicare & Medicaid Services data.

Legal Challenges to ACA Subsidies, Enrollment, Top Issues in 2015 for Health Insurers

Affordable Care Act enrollment is clearly proceeding more smoothly for 2015, the second year of implementation of the law’s primary provisions, than in the first year, according to a survey of the Health Insurance Report Advisory Board conducted by Bloomberg BNA.

ACA Enrollment Groups Shift Focus to Tax Liabilities

Affordable Care Act enrollment groups are beginning to emphasize the law’s tax liabilities that people may face if they don’t get coverage.

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...

Does Having More ACA Health Plan Options Cause Premiums to Rise?

Having more health plan choices may not be better for people who buy subsidized coverage through marketplaces created under the Affordable Care Act, according to a RAND Corp. study released Jan. 6.

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.

A Look into the Crystal Ball for 2015 Health-Care Fraud Trends

Every year Bloomberg BNA’s Health Care Fraud Report’s advisory board is asked to make predictions about the coming year, and from a look at what they said, 2015 is going to be a busy one.

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.

Security Project Aims to Protect Infusion Pumps Against Cyberattacks

The National Cybersecurity Center of Excellence at NIST and researchers at the Technological Leadership Institute at the University of Minnesota have launched a draft project to study methods for securing networked infusion pumps.

Government Issues Proposals to Change Summary of Benefits, Uniform Glossary

Three agencies issued a proposed rule Dec. 22 that would make changes to the information health plans must provide consumers under the Affordable Care Act.

Eighty-Nine New ACOs to Join Medicare, CMS Says

The CMS said Dec. 22 that 89 new accountable care organizations will join the Medicare Shared Savings Program in January.

High Court Sets Date For Arguments in ACA Subsidies Case

The U.S. Supreme Court will hold oral arguments March 4 on a much-watched case (King  v. Burwell) involving whether people buying Affordable Care Act health insurance in all 50 states can receive subsidies.

ACA Premiums Rise, but Increases Low for Most, McKinsey Finds

Consulting firm McKinsey & Co., using a comprehensive database of all Affordable Care Act exchange plans for 2014 and 2015, found that ACA premiums are rising in 2015, but the increases are low for most consumers.

People Without Health Insurance Declined To 17 Percent, Early 2014 Survey Finds

National Health Interview Survey data on health insurance coverage released Dec. 16, the first federal survey data to capture the effects of the Affordable Care Act, found sharply dropping rates for people without health insurance.

Is CMS’s Hospital-Acquired Conditions program unfair to hospitals?

Medicare payments to about 724 hospitals will be reduced 1 percent in fiscal 2015 under a program that penalizes providers for failing to adequately control hospital-acquired medical conditions, but hospitals claim the CMS initiative unfairly punishes providers.

OIG Enforcement Efforts Hit the Jackpot with $4.9 Billion in Recoveries in FY 2014

It's the end of the year, which means we're faced with a deluge of top-10 movie lists, New Year's resolutions and last but certainly not least, a recap of OIG enforcement efforts for FY 2014. And from a look at the recently released results, it was a good year.

257,000 Providers, 200 Hospitals Face Meaningful Use Penalties in 2015, CMS Says

More than 257,000 doctors will see a 1 percent cut in their Medicare reimbursements in 2015 for failing to adopt an electronic health record and meet the requirements of the meaningful use...

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.

What Should OMHA Do to Clear the Medicare Claims Appeals Backlog?

It obviously depends on your perspective. The nation's largest hospital industry group recently blamed  Medicare Recovery Audit Contractors (RACs) for the backlog and called for fundamental...

How Significantly Will Medicaid Primary Care Payments Drop Next Year?

Unless Congress acts, quite a lot. A provision of the Affordable Care Act that temporarily boosted Medicaid primary physician payments will expire at the end of the year. According to a study from...

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.

Is ICD-10 Really as Bad as Darth Vader?

I'll admit it, I'm a fan of the Star Wars movies, but I never expected them to become part of the ongoing debate over ICD-10.

Patient Advocates Call for Ban on Re-Identifying Health Data.

Private companies and the federal government should issue a ban on the on the re-identification of de-identified health data, the National Partnership for Women and Families, a patient advocacy...

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.


Meaningful Use Attestation Rate Continues to Grow, But CHIME Says It's Still Too Low

The number of health-care providers and hospitals that have attested to meeting Stage 2 meaningful use requirements in 2014 nearly doubled during November but the overall number of providers and...

Industry Groups Say No Thanks to OIG's Gainsharing Safe Harbor

Industry groups representing both biotechnology companies and medical device manufacturers have made it clear that they're not fans of an OIG  proposed rule  that would create a safe harbor for certain gainsharing arrangements, according to public comments on the proposal.

Former CBO Director Predicts ‘Disaster’ From Incorrect ACA Subsidy Payments

Former Congressional Budget Office Director Douglas Holtz-Eakin predicted that, because of inaccurate payments for 2014, some Affordable Care Act health insurance enrollees will have to reimburse the government for subsidies when they file tax returns in 2015.

Republicans Once Again Take Aim at ACA’s Cost Cutting Panel, IPAB.

Group of 24 lawmakers says Supreme Court should take up challenge to Independent Payment Advisory Board.

Health IT Standards Group Launches Project to Expand Use of API Platform

The health information technology standards-setting organization HL7 has partnered with several major electronic health record developers and four health-care systems to promote the use of its...

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.

Urban Institute: Number of Uninsured Adults Drops by Nearly 11 Million Under ACA

The number of uninsured nonelderly adults dropped more than 30 percent between September 2013 and September 2014 as millions of previously uninsured people enrolled in Affordable Care Act marketplace plans and Medicaid, according to a survey released Dec. 3 by the Urban Institute.

Health Care Spending Growth Hits Historic Low. Will it Rise Faster as the Economy Approves?

Health care spending grew 3.6 percent in 2013, the lowest on record, the CMS said.

Medicare Targets Felons and Debtors with Final Rule

A recent Medicare  final rule  has declared war against providers with felony convictions and unpaid Medicare debt, authorizing new enrollment denials and revocations.

RAND: Benefits of Health Information Exchanges Rarely Studied

Health researchers have studied less than a dozen health information exchanges (HIEs) despite the nearly $600 million in federal investments made to establish and sustain roughly 100 HIEs over...

Cost to Bring Drug to Market Is $2.5 Billion, Maybe More

It now costs $2.56 billion to bring a drug to market, according to a new study, although some say even that newly raised figure is too low.  The study by the Tufts Center for the Study of Drug...

Data Analysis in the Big D: Notes from the NHCAA's Annual Training Conference

Data analysis was one of the hot topics everyone was discussing at the recent National Healthcare Anti-Fraud Association's Annual Training Conference in Dallas, and I heard some great speakers...

CMS Extends Comment Deadline for Home Health Rule

The CMS has extended by 30 days the comment period on a proposed rule updating Medicare and Medicaid conditions of participation for home health agencies.

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...

Patents in Europe: Unitary, Transitions, Opt-Outs, Opt-Back-Ins

The unitary patent and patent court in Europe are coming into being, although the next seven years will see combinations, opt-outs and opt back ins, an attorney told a biotech conference. I...

What Are the Prospects for Rep. Brady’s Bill on Medicare Hospital Stay Policies?

House Ways and Means Health Subcommittee Chairman Kevin Brady (R-Texas) Nov. 19 unveiled a  discussion draft  of a bill that would change how Medicare pays for some hospital stays. In particular,...

EHR Vendors, Provider Organizations Need Better Partnerships, Researcher Says

One health researcher thinks a lot of health-care organizations and electronic health record vendors could use some couples counseling.

GAO Says Medicare’s Transparency Tools Aren’t Very Useful. But Is CMS Going to Fix Them?

CMS's websites to help people shop for providers don't present information about costs or quality in a consumer-friendly manner, according to a recent investigation.

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.

New CBO Estimate of ‘Doc Fix' Bills $144 Billion Over 10 Years

The Congressional Budget Office Nov. 14 said legislation (H.R. 4015, S. 2000) to repeal and replace the Medicare physician payment system would cost $144 billion from 2015 to 2024.

Will CMS Make Another Patient Status Appeals Offer?

During a Nov. 13 session of the National RAC (Recovery Audit Contractor) and MAC (Medicare Audit Contractor) Summit , Joe Schindler, vice president of finance at the Minnesota Hospital...

Election Results May Have Caused HHS to Withdraw Controversial Drug Discount Rule, Attorney Says

Election Results May Have Caused HHS to Withdraw Controversial Drug Discount Rule, Attorney Says

What Time Is It? Time for Another Prior Authorization Demo from CMS

For all those fans of prior authorization demonstration programs, get ready to be happy. A CMS notice recently  announced  that it will debut a three-state Medicare prior authorization program for repetitive non-emergency ambulance services on Dec. 1

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...

ONC Brings in Private-Sector Innovators to Tackle Patient Data Matching Issues

The Office of the National Coordinator for Health Information Technology has charged two temporary hires with solving one of the health IT industry's most significant problems—accurately matching...

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.

Can the ACA Survive Another Supreme Court Review?

Supreme Court agrees to take case concerning health insurance subsidies under the ACA.

Republicans Took the Senate. Does That Mean They Can Fix Doc Payments? Unlikely.

Despite Republicans taking control of the Senate after the Nov. 4 elections, the odds haven't really improved for passing a permanent fix for Medicare's SGR formula.


Has Progress Slowed in Getting Kids Insured?

A report from Georgetown University says progress in getting kids insured appears to have slowed.

CMS Ready to Spread More Sunshine By the End of the Year

For those who can't enough Sunshine, you're in luck. I recently attended the Pharmaceutical Compliance Congress and Best Practices Forum and CMS's Doug Brown said the agency is slated to release...

Patients Concerned About Privacy, But Support Data Sharing, ONC Finds

Americans worry less about the privacy of their personal health data when their providers use an electronic health record than when their records are stored on paper, according to results of...

Should CMS Institute RAC Reforms to Reduce Appeals Backlog?

Today, the CMS issued a request for information seeking input about ways to reduce the backlog of appeals currently at administrative judge law (ALJ) level. In its request, the CMS said it is...

Medicaid Directors: These Cures are Killing Us

Medicaid directors want Congress to take action to curb the high price of specialty drugs like Sovaldi.

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.

Is the OIG Planning to Review the Health-Care Exchanges?

The health-insurance exchanges created by the Affordable Care Act have faced their fair share of controversy, and judging by the OIG's recent FY 2015 work plan , they'll soon be in for more. The...

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.

Texas Hospital Gets a Halloween Treat: A Stark Law Exception

Providers have an almost uniform dislike of the Stark law, which many consider overly technical and burdensome. While there are certain exceptions to the law, they aren't readily available and are...

CMS to Create Frightful Night for Health Care Stakeholders?

CMS could publish as many as three Medicare payment rules on Halloween.

Why is the OIG Extending the Comment Period for Permissive Exclusions?

Comment periods in the Federal Register are usually set in stone, giving the public anywhere from 15 to 90 days to weigh in government proposals. However, circumstances can change, as happened...

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.

ACA Applicants Should Use Paper Appeals: Electronic Appeals Not Ready for Prime Time

The Centers for Medicare & Medicaid Services Oct. 23 extended the period for using paper applications for appeals in the federally-operated Affordable Care Act health insurance marketplaces for another year through 2015.

Improper Federal Payments Are Back, This Time in Texas

To the litany of reasons why the federal government makes improper payments, add this: providers of non-emergency medical transportation (NEMT) for Medicaid patients submitted claims to Medicaid...

FDA, Industry Reps Say Providers, Device Makers Should Share Data on Cyber Risks

Health-care organizations and medical device manufacturers should share more information with each other about medical device cybersecurity vulnerabilities, federal health and technology...

Is Congress Ready to Take Action on Health Information Exchange?

I trekked out to Reston yesterday to take in WEDI's fall conference, and speakers were eager to talk about the benefits of health information exchange and what the future holds. Mary Grealy, the...

CMS Outlines Methodology to Determine Payments Under Basic Health Program

The CMS has released methodology and data sources for determining federal payments in 2016 to states establishing an alternative coverage program for low-income people under the Affordable Care...

Hospital Associations Supporting CMS Price Transparency Requirement

A new CMS requirement for hospitals to publicize a list of their standard charges for items and services enjoys support from the Federation of American Hospitals and the American Hospital...

Can Tax Revenue Really Be Used to Pay for Out-Of-Pocket Expenses?

At first glance, the idea that a township could use tax revenue to cover out-of-pocket expenses for patients using emergency ambulance services sounds like a clear violation of the anti-kickback...

Second ACA Enrollment Effort Entering `Last Stretch’

With the second open enrollment period for the Affordable Care Act marketplaces set to start Nov. 15, the government’s chief executive officer in charge of the operation gave the health...

Looking for the ACO Waiver Final Rule? Wait Until Next Year

If you're eagerly awaiting the publication of the CMS and OIG final rule on fraud and abuse waivers for ACOs, I've got some bad news for you: it's going to be another year. CMS and OIG recently ...

How Will Medicaid Plans Cover Specialty Drugs?

As a new hepatitis c drug is approved with a high price tag, state Medicaid plans are trying to figure out how to minimize the impact of the cost.

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. ...

Burwell Tries to Control Expectations Before Second ACA Open Enrollment

In a wide ranging question-and-answer session with the media, Department of Health and Human Services Secretary Sylvia Mathews Burwell Oct. 9 tried to control expectations about the upcoming...

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...

Speaker Paints Stark Picture of Un-Revised Patent Eligibility Guidance

The Patent and Trademark Office has promised revisions in its guidance on the patent eligibility of naturally-occurring products, and one conference speaker employed a unique way to...

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 ...

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...

Industry Groups Asking Congress to Outline FDA Oversight of Health IT

Nearly 60 health information technology groups and various industry associations are circulating a letter among member of Congress asking for legislation that clarifies the Food and Drug...

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...

CMS Needs Better Oversight of State Medicaid Managed Care Plans

CMS isn't doing enough to enforce requirements that states provide adequate access to doctors, OIG says in a recent report.

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...

Device Makers Should Think About Cybersecurity, FDA Says

Device manufacturers should consider cybersecurity risks as part of the design and development of their products, the Food and Drug Administration said in releasing a final guidance Oct. 1. ...

GAO: Integrating Benefits for Duals May Not Produce Medicare Savings

The GAO is questioning the push by the CMS and Congress to better integrate care for the disabled who are eligible for Medicare and Medicaid, saying that while it may improve quality outcomes,...

As Meaningful Use Reporting Deadline Approaches, CMS Announces Hardship Exception Figures

Roughly 44,000 providers applied for hardship exceptions from the meaningful use program this year in hopes of avoiding a Medicare penalty next year, the Centers for Medicare & Medicaid...

Just How Viable an Option is the Private Option?

In spite of recent GAO findings, analysts say the private plan option for expanding Medicaid can work in other states.

Public Citizen Wants Medicare to Change Physician Pay Rate-Setting Procedure

AMA, RUC, health care reform, Obamacare, ACA, physicians, Medicare, Public Citizen, SGR

McKinsey: ACA Marketplace Competition Increasing But Premiums Could Rise for Subsidy-Eligible

Health care analysts have been warning that if people who receive subsidies for their Affordable Care Act marketplace health plans rely on automatic renewals during open enrollment for...

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...

Analysis Finds Number of 2015 Plans Lowest Since Start of Part D Drug Benefit

Obamacare, Medicare, Medicare prescription drugs, CMS, prescription drugs, seniors

Federal Security Officials Say Cyberattacks on Health Companies Expected to Increase

Federal officials are warning health-care companies to expect more cyber attacks in the coming year. Over the past two years, hacking and other malicious cyberattacks accounted for only about...

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. ...

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...

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...

Researchers: Electronic Health Records Can Help Make Patients Safer

Adoption of an electronic health record system with advanced physician alerts and order entry assistance can significantly improve patient safety in a hospital or physician group practice,...

ACA Rate Review Provision Saved Consumers $1B in 2013, HHS Says

The Department of Health and Human Services is touting savings realized by consumers as a result of an Affordable Care Act provision requiring health insurers to justify premium increases. ...

Using Copayment Coupons for Part D Drugs? OIG Says Think Again.

A copayment coupon sounds like a great idea, giving patients the ability to pay little or no copay for their prescription drugs. Mix a copayment coupon with a drug paid for by Medicare Part D...

Unnecessary Chemo is the Worst Kind of Health-Care Fraud

Health-care fraud, in all it's various and sundry forms, is wrong, but never more so than when patient care is affected. A recent guilty plea from a Detroit-area oncologist is a case in point. Farid...

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...

Telemedicine Debate Continues Amid New Guidance, Reports

The debate over how to improve access to telemedicine services continued this month in the wake of new model legislation from the Federation of State Medical Boards aimed at helping states...

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...

WellPoint, Blue Cross and Blue Shield Plans Leading Market Share in 2014 ACA Marketplaces

Avalere Health LLC confirmed anecdotal evidence that health insurer WellPoint Inc. and various independent Blue Cross and Blue Shield plans captured the greatest percentage of customers in the...

Are Rural Health Clinics Getting More Than They Deserve from Medicare?

Rural health clinics (RHCs) are designed to serve some of the most remote parts of the country, and as such, they receive extra Medicare and Medicaid reimbursements for their services. However, a...

Did HHS Break Its Own Medicaid Waiver Rules?

A recent GAO report finds Arkansas's plan to use premium support to expand Medicaid isn't budget neutral, and faults the HHS process to approve such plans.

Louisiana Overpaid Hospitals $3M in Medicaid Meaningful Use Payments

Louisiana's Medicaid agency overpaid more than a dozen hospitals a total of $3.1 million in Medicaid meaningful use incentive payments in 2011, according to a Sept. 8 report by the Department...

Burwell Calls for Cooperation, End to Partisan Attacks on ACA

In her first major public remarks since being confirmed in June, HHS Secretary Sylvia Mathews Burwell Sept. 8 defended the Affordable Care Act and called for an end to partisan strife over...

Kaiser Study Finds Costs Dropping For Benchmark ACA Health Plans

A perpetual question about the Affordable Care Act is whether health insurance plans offered through its marketplaces will actually be affordable, or whether the law will result in premium...

Industry to CMS: Keep the CME Sunshine Reporting Exemption

It's official. The vast bulk of health-care industry stakeholders want CMS to keep the continuing medical education (CME) reporting exemption under the Open Payments program. According to the CME...

House Set to Vote on Group Insurance Plans

House Republicans promise to pass a bill allowing employees to keep non-ACA compliant group health plans.

CMS, Treasury to Team Up on Reducing Improper Payments

CMS and the Treasury Department are going into business together, with the end goal of reducing improper payments. A recent CMS notice announced an upcoming computer matching program, in which the...

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...

Meaningful Use Relief Rule Doesn't Go Far Enough, Health IT Groups Say

The final rule intended to ease EHR certification requirements for meaningful use participants this year offers only temporary relief for those struggling to meet the program's requirements, health information technology industry associations said Sept. 2.

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...

Measuring Individual Docs for Quality May Not Be Worth Effort, MedPAC Says

Congress's Medicare advisers are urging the Centers for Medicare & Medicaid Services not to focus on the performance of individual physicians in the agency's quality measurement programs...

CMS Final Rule Allows Consumers to Automatically Re-Enroll for 2015 on

With the second open enrollment period of the Affordable Care Act scheduled to start Nov. 15 for the 2015 plan year, the Department of Health and Human Services’ Centers for Medicare &...

The Doc Fix is Still Cheap, Medicare Spending Will Slow, and Other CBO Predictions

CBO predicts Medicare spending will slow over the next decade. In the short-term, Medicaid spending will rise considerably because of states expanding coverage under the Affordable Care Act.

Healthcare Efficiency Index Highlights Savings From Administrative Simplification

Increased adoption of information technologies to process health-care claims electronically could save providers and payers $8 billion next year, according to a report by the Council for...

Study: 7 Million Could Get Affordable Care Act Coverage Outside of Open Enrollment

While the Obama administration has been proud of getting more than 8 million people to sign up for health coverage during the first open enrollment period of the Affordable Care Act, millions more...

Affordable Care Act Risk Sharing Rules May Give Taxpayers Unlimited Exposure, Report Says

Among the many hot-button issues involving the Affordable Care Act are risk sharing rules designed to protect health insurers from ending up with higher-than-average numbers of enrollees who have...

350,000 Who May Drop Coverage Would Buy Lower-Value Plans

Health insurers have suggested that the Affordable Care Act be amended to allow for more affordable plans that cover the same list of services but a lower share of claims. Aug. 18 the Council for...

Are Nursing Homes Doing Enough to Report Abuse Allegations?

Federal regulations require nursing homes to report any abuse and neglect allegations to the proper authorities, but it looks like barely half of nursing homes are actually doing this correctly. A...

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...

Health Data Exchange Stymied By ‘Lack of a Business Case,' Policy Group Says

The primary barrier to electronic health information exchange is “the lack of a business case” for doing so, according to a policy brief published Aug. 11 by Health Affairs.   Despite evidence...

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.

Proposed 2015 Health Insurance Premiums Up 7.5 Percent on Average

Average proposed health insurance premiums for 2015 are 7.5 percent higher than 2014, beating predictions from experts that they’d increase at a faster rate, PricewaterhouseCoopers LLP (PwC) reports....

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 Projects Inpatient Hospital Payments Will Decrease by $756 Million in FY 2015

Hospitals say the disproportionate share program cuts in the final Medicare payment rule issued by the Centers for Medicare & Medicaid Services Aug. 4 will hurt their ability to provide...

CMS Proposed Rule Would Result in Lower Subsidies, Milliman Finds

A proposed rule by the Centers for Medicare & Medicaid Services aimed at simplifying re-enrollment for the 8 million people who signed up for health insurance in the Affordable Care Act...

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.

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...

Group Health Plans That Don’t Comply With Affordable Care Act Could Be Continued Under Bill

With two votes from Democrats, the House Energy and Commerce Committee July 30 approved legislation that would allow health insurers to offer group plans that were in effect in 2013, including old...

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.

Telehealth Advocates Hopeful About Future Policy Changes

The likelihood Congress will move on any bills this year—particularly health care legislation—is slim. But, telehealth advocates are encouraged by what they see as growing bipartisan support for...

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).

Workforce Survey Finds ‘Strong' Growth for Health IT

More than 80 percent of health-care organizations hired at least one health information technology expert in 2013, an increase over previous years, according to a survey released July 22 by...

Providers Want More Clarity in Final EHR Flexibility Rule

Health care providers want assurances that a proposal intended to give them flexibility in the federal government’s electronic health record incentive program won’t come back to bite them in...

If Your Sunshine Act Submissions Aren't Accurate, You Could Be in Big Trouble

We're less than two months out from the public release of Sunshine Act data, and while the initial data submissions have already been made, it's an ongoing process and the penalties for inaccuracy can be steep.

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...

CMS Exempts U.S. Territories From Major ACA Requirements

The five U.S. territories have been forced to become an experiment in what happens when the guaranteed availability, community rating and other reforms of the Affordable Care Act are applied without...

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.  

Kaiser Family Foundation: 10.6 Million Got Assistance to Enroll in Affordable Care Act Health Insurance Marketplaces

After surveying 843 programs that provided assistance to people enrolling in coverage through the Affordable Care Act health insurance marketplaces during the first open enrollment period in...

Biotech Industry Optimistic But Value Remains the Issue

At the BIO 2014 International Convention in San Diego last month, there was a strong sense of optimism, along with acknowledgements of not-so-hidden dangers around, which became more apparent on...

Providers Remain Largely Unaware of Health IT-Related Safety Issues, Report Says

Health-care providers are generally unaware of the potential hazards posed by the use of health information technologies, according to a research report published by the Office of the National...

Senators Question Pricing of Gilead's Hepatitis C Drug

Senate Finance Committee Chairman Ron Wyden (D-Ore.), and senior Finance Committee member Chuck Grassley (R-Iowa), July 11 requested detailed pricing information on the Hepatitis C virus drug...

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.

GAO Says Excluding Brokerage Commissions from ACA Medical Loss Ratio Would Have Decreased Rebates

Health insurance brokers have mounted an offensive to try to get their commissions excluded from administrative expenses that are limited under the Affordable Care Act. They have pointed to surveys...

No Evidence of Medicare Upcoding Amid Fears, Growth in EHRs, Study Says

There is no evidence suggesting hospitals are systematically using electronic health records (EHRs) to claim a sicker patient population through billing codes, or upcode, to increase Medicare...

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.

White House Ratchets Up Pressure On States to Expand Medicaid

White House says states that haven't expanded Medicaid have missed out on $88 billion in federal funding.

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.

Meaningful Use-Certified EHRs Not Always Interoperable, Study Finds

Electronic health record systems certified for use in Stage 2 of the meaningful use program aren't always interoperable with other EHR systems, according to a study published June 26 in the...

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...

Contraceptive Insurance Rule Narrowed by U.S. High Court

Congressional reaction to the U.S. S upreme Court’s decision in the Hobby Lobby case June 30 broke down along partisan lines, with Republicans praising the decision as a victory...

Hospital Administrators See ICD-10 as Problematic for Health IT, Survey Says

Hospital administrators expect that the anticipated conversion to the  ICD-10  (International Classification of Diseases, 10th Revision) code set will immediately make a host of health IT activities...

Adjusted Vs. Unadjusted Savings in CMS's Fraud Prevention System

I briefly touched on the recent CMS predictive modeling report in a previous blog post, but I think it merits a second post, if only to talk about the introduction of adjusted savings.

House, Senate Leaders Introduce Bill to Change Post-Acute Care System

Change may be coming to Medicare’s post-acute care system, but it may take a decade for it to arrive. Leaders of the Senate Finance and House Ways and Means committees June 26 introduced...

Do Medical Device Data Systems Pose a Risk to Patients? FDA Says No.

FDA proposes to exempt medical device data systems from regulations because they pose a low risk to patients. 

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.

Lab Arrangements May Violate Anti-Kickback Law, OIG Says

The Department of Health and Human Services Office of Inspector General is warning clinical laboratories and physicians that providing remuneration to physicians to collect, process and package...

Stronger Economy, Specialty Drug Use Seen Leading to Higher Employer Health-Care Costs

The five-year anomaly of tempering health-care costs in the U.S. will end in 2015, PricewaterhouseCoopers LLP (PwC) said in a report on health-care market trends released June 24. In recent years...

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.

Burwell Gives Legal Justification For Risk Corridor Payments

Congressional Republicans as well as the nonpartisan Government Accountability Office and Congressional Research Service have questioned whether the Obama administration has legal authority to make...

Kaiser Says 57 Percent of ACA Enrollees Previously Uninsured

Among the many important data points in dispute concerning the Affordable Care Act is how many of the enrollees in the ACA marketplaces were previously uninsured. Covering the uninsured, after all,...

Insurers Expect $1 Billion in Risk Corridor Payments, Committee Finds

The Affordable Care Act includes several provisions to keep premiums stable if health insurers end up with sicker-than-expected enrollees. Congressional Republicans have charged this could lead to a...

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.

Senior Citizens Responsible for $9 Million in Medicare and Medicaid Recoveries in 2013

Senior Medicare Patrols (SMPs) were responsible for $9 million in expected Medicare and Medicaid recoveries in 2013, a recent OIG  report  said, thanks to fraud, waste and abuse referrals passed on to CMS contractors.

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...

MACPAC Recommends Congress Extend CHIP Funding for Two More Years

The Medicaid and CHIP Payment and Access Commission June 13 recommended Congress extend federal funding for the Children's Health Insurance Program for an additional two years.   In its June...

The High Cost of Avoidable Readmissions

Lawmakers are beginning to take notice of hospital concerns over the Medicare Hospital Readmissions Reduction program.

Narrow Health Care Provider Networks To Become More Prevalent

The controversial "narrow networks" featured in many of the Affordable Care Act marketplace health plans are likely to become more prevalent in the commercial market and in Medicare Advantage plans,...

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.

Up to $60 Million Available for Marketplace Navigators, CMS Says

The Centers for Medicare & Medicaid Services is making up to $60 million available for the next round of grants to support health-care navigators for certain states under the Affordable Care...

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.  

Congressional Budget Office Lowers Affordable Care Act Penalty Projections

The Congressional Budget Office (CBO), on which Congress relies for estimating the costs of legislation, June 5 reduced its estimate of the number of people who will end up paying penalties under...

Meaningful Use Program Payments Approach $24 Billion; Enrollment Still Lags Behind 2013

As of April, the federal government has paid more than $23.7 billion in incentive payments to health-care providers and hospitals through the meaningful use program, which pays Medicare and...

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...

HHS Announces Up to $300 Million for Community Health Centers

The Department of Health and Human Services said June 3 it is making up to $300 million available to community health centers to improve the care they offer. The funding, included in the...

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...

Federal Advisory Group to Help Design Proposed Health IT Safety Center

A federal advisory group in July will offer recommendations to federal regulators on the governance and structure of the proposed Health Information Technology Safety Center, a central hub for...

HHS Should Close Loophole On Malpractice Reporting, Group Says

Physicians and other health-care providers should be required to report medical malpractice payments to the federal government's National Practitioner Data Bank (NPDB), the advocacy group Public...

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.

State Medicaid Programs Struggle to Process Applications From Federal Marketplace

With growing backlogs, state Medicaid programs continue to have “enormous problems” processing new enrollees using information provided by the federal online health insurance marketplace,...

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.

Rockefeller Pushes Medical Loss Ratio Provision for Medicaid Managed Care

The requirement that health insurers spend at least 80 percent of premiums on medical claims or quality improvements was added to the Affordable Care Act as a substitute for the so-called public...

AHIMA Finds Little Information Governance in Health Care

The majority of health-care organizations have no strategy for managing the health information they generate and store, officials from the American Health Information Management Association said...

CMS Trims Rule on Part D, Medicare Advantage in Final Version

The Centers for Medicare & Medicaid Services May 19 released a watered-down final rule governing Medicare’s managed care and prescription drug programs that eschewed numerous controversial...

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.

Senate Republicans Want Some States To Repay Health Exchange Funding

Senate Republicans want states that have abandoned their health care exchanges established under the Affordable Care Act to repay the federal grants they received to help build them. The proposed...

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.

Health Insurers Report High Premium Payment Rates in ACA Marketplaces

Premium payment rates appear to have been reasonably high for enrollees in Affordable Care Act health insurance marketplace plans whose payment due dates have passed, several large health insurers...

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.

Health Data Exchange Growing Unevenly Across the Country

The number of acute-care hospitals that electronically exchanged health information with a health-care provider outside their information network reached an all-time high in 2013, according to ...

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 &...

Value-Based Insurance Design Winning Bipartisan Support

Despite the intense controversy over the Affordable Care Act, attempts to reform the U.S. health care delivery system are winning bipartisan support in both houses of Congress, a Republican...

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.

Increase in Health IT Use Raise Patient Safety Concerns

The rapid adoption of health information technologies, namely electronic health records, by health-care providers and hospitals in recent years has researchers worried about an uptick in data...

Only A Quarter of People Eligible For Subsidies Under Affordable Care Act Signed Up

As few as 25 percent to 30 percent of people eligible for subsidies in the Affordable Care Act health insurance marketplaces have signed up for coverage.  That means the marketplaces aren't...

Insurers Ask For Money, Compliance Safe Harbor for 2015 Marketplace

Health insurers are asking the federal government for more money to make up for the Obama administration's policy changes extending plans that don't comply with the Affordable Care Act to continue...

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.

Researcher Look to Meaningful Use Stage 2 for Quality Improvements

Researchers at Brigham and Women's Hospital and Harvard Medical School in Boston studying the impact of participation in Stage 1 of the meaningful use program told Bloomberg BNA April 21 they...

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.

FDA Warns of Cancer Risk From Common Hysterectomy Technique

The FDA is discouraging the use of a common hysterectomy procedure because of the risk of spreading cancer.

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.

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...

CBO Lowers Estimate of Health Insurance Gains under Affordable Care Act

The Congressional Budget Office once again lowered its estimate of the number of people expected to gain health insurance under the Affordable Care Act.  In an April 14 report , the CBO projected...

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.

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.

File Under More of the Same: OIG Releases Another Report on Questionable Medicare Billing

There are few things in life that are certainties, beyond the cliched death and taxes, but OIG reports uncovering potential Medicare fraud are fast climbing up the list. A recent report discovered that physicians billed Medicare $139 million for questionable electrodiagnostic tests in 2011.

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.

CMS Warns Against Snap Judgments About Physician Payment Data

The Centers for Medicare & Medicaid Services April 9 urged caution about drawing quick conclusions about potential fraudulent or wasteful activities by providers who received particularly high...

Outlook is Positive for Competitive Bidding, But More Monitoring Needed, OIG and GAO Say

Medicare's durable medical equipment competitive bidding program is generally in compliance with federal requirements and is reducing DME utilization, but continued monitoring and oversight are needed to ensure patient access isn't compromised, according to recent reports from the OIG and GAO.

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...

State Health Insurance Marketplace Directors Questioned About Problems

The directors of five Affordable Care Act state health insurance marketplaces that had major technical problems were hauled before Congress at an April 3 hearing to explain what went wrong.  They...

Despite Payment Decreases Quality Reporting, eRx Incentive Programs Continue to Expand

Participation in the Medicare Physician Quality Reporting System (PQRS) and the Electronic Prescribing Incentive (eRx) Program grew by more than 151,000 providers between 2011 and 2012 even as...

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.

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.

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...

Hospitals Get Slow Start on Stage 2 Of Meaningful Use Program

No hospitals have yet attested to meeting the requirements of Stage 2 of the meaningful use program, Elizabeth Holland, director of health information technology initiatives at the Centers for...

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.

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...

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.

Obama Administration Again Delays Affordable Care Act Provision

Once again the Obama administration has backtracked on its repeated assertions that it would not delay implementation of the controversial Affordable Care Act. March 26 it released guidance giving...

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...

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.

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...

HHS Posts Wide Range of Affordable Care Act Requirements

In a massive regulatory dump, the Department of Health and Human Services March 14 filed a 279-page proposed rule, an interim final rule and three other guidance documents on a wide range of...

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."

CMS Offers Choices for Hospice Patients

A new CMS pilot program will allow hospice patients to receive end-of-life care while also being treated to cure their disease/condition.

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...

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 ...

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.

American Smartphone Use to Capture mHealth Market Share

The United States is expected to hold the world’s largest share of the mobile health market through 2017 thanks to its high rate of smartphone use, according to a March 13 report by the Brookings...

Health Insurance Enrollment Under Affordable Care Act Reaches 4.2 Million

Enrollment in health insurance through the online marketplaces created by the Affordable Care Act reached 4.2 million March 1, the Department of Health and Human Services announced March 11. That...

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.

Taking a Bite Out of Crime: Medicaid Fraud Fighters Recover $2.5 Billion in FY 2013

Fiscal year 2013 turned out to be a banner year for fighting Medicaid fraud, as state Medicaid Fraud Control Units (MFCUs)  recovered almost $2.5 billion associated withe criminal and civil investigations.

Percentage Without Health Insurance Continues to Fall, Gallup-Healthways Finds

The Gallup-Healthways Well-Being Index poll gave a boost to the Affordable Care Act March 10 with its findings that the percentage of Americans without health insurance continued to fall, to 15.9...

Number of Medicare Enrollees To Rise By One-Third by 2024, CBO Says

Mirroring an increase in the number of Americans reaching age 65 over the next decade, the Congressional Budget Office says the number of Medicare beneficiaries will rise by more than one-third...

White House Budget Rehashes Medicare Ideas.

Many of the Medicare proposals in the White House FY 2015 budget request are the same as last year.

People With Non-Compliant Policies Given Two-Year Reprieve From Health Care Law

Individuals and small businesses whose health insurance policies were cancelled for not meeting the requirements of the Affordable Care Act were given a two-year reprieve under guidance released...

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.

Obama Budget Proposal Calls for More Money, New Tactics in Anti-Fraud Fight

If presidential  budget proposals  automatically became law, then the fraud-fighting Health Care Fraud and Abuse Control (HCFAC) account could expect a 9 percent increase in discretionary spending over the estimated fiscal year 2014 level ($294 million to $319 million).

White House Expresses Support For Congressional Doc Fix Efforts

The White House has lent its support to congressional efforts to overhaul Medicare’s problematic physician payment system. In its fiscal 2015 budget plan released March 4, the White House said it...

Mobile Devices Present But Not Contributing to EHRs, HIMSS Survey Says

Although most health-care providers want to be able to use their laptops, smartphones and other mobile devices to access and modify their patients’ health records, only a fraction of health-care...

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.

At HIMSS in Orlando: Interoperability at Center of Discussions

One of the many buzz words of this year’s Healthcare Information and Management System Society’s (HIMSS) Conference has been interoperability. Many of the more than 36,000 vendors and health-care...

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 Seeks Comments on Expanded DME Competitive Bidding

The Centers for Medicare & Medicaid Services is seeking public comment on how best to expand its competitive bidding program for durable medical equipment to more regions around the country....

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.

States Spend One-Third of Medicaid Money On Small Fraction of Beneficiaries, GAO Says

States are spending nearly one-third of their Medicaid money on the most expensive beneficiaries, who are just a small fraction of the total Medicaid population, according to a report released...

Device Reporting Goes Electronic

FDA is requiring manufacturers to submit electronic adverse event reports starting in 2015.

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.


Bipartisan Group of 40 Senators Asks CMS To Avoid MA Cuts in 2015

Medicare Advantage payment rates for 2015 are due out Feb. 21, and the possibility that the Centers for Medicare & Medicaid Services will cut plan payments has got the attention of lawmakers....

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...

Has ICD-10 Implementation Just Gotten A Lot More Expensive?

Physician practices were always aware that transitioning to the new ICD-10 codeset would be expensive, but a recent report commissioned by the American Medical Association estimates the costs might...

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...

Heavy Female Concentration More a Worry Than Lack of Young Adults in ACA Marketplaces

Despite the heavy focus on whether the Affordable Care Act health insurance marketplaces are getting enough young enrollees to help keep health costs and premiums low, that may not be as much of a...

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”...

House, Senate Lawmakers Unveil Permanent Doc Fix; Payfors Still Unknown

I would not break out the champagne just yet...still, the announcement today that House and Senate lawmakers have reached an agreement to eliminate the sustainable growth rate formula in the...

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...

CMS Gives Patients Access to Lab Test Results

New CMS final rule makes it easier for patients to access test results from medical labs directly.

Regulatory Uncertainty Remains in the Health Software Market

The SOFTWARE Act ( H.R. 3303 )  introduced last fall by Rep. Marsh Blackburn (R-Tenn.) was intended to relieve regulatory uncertainty for health care software developers. Response to the bill,...

Medicare Spending Rose by Just 2 Percent in 2013, CBO says

Medicare spending grew by just 2 percent in 2013, the lowest rate since 1999, the Congressional Budget Office said Feb. 4 In a report on the federal budget and the economy, the CBO projected...

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...

Fraction of Physicians Will Avoid Stage 2 of Meaningful Use

More than 10 percent of office-based physicians are not planning to participate in Stage 2 of the meaningful use program, according to a Centers for Disease Control and Prevention survey. The...

Medicare Ups the Ante on Temporary Enrollment Moratoria

For only the second time ever, Medicare has issued temporary enrollment moratoria for home health agencies operating in Fort Lauderdale, Fla., Dallas, Houston and Detroit, as well as for...

CMS Touts ACO Success, Says Providers Saving Money While Improving Quality

The Centers for Medicare & Medicaid Services said this week that Accountable Care Organizations are beginning to bend the health care cost curve while at the same time improving the quality of...

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...

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...

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...

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 ...

Only 11 Percent of Health Insurance Enrollees Previously Uninsured

The Affordable Care Act was aimed at reducing the number of people without health insurance in the United States.  So perhaps the most important statistic for its first open enrollment period from...

Is Medicare Mailing Statements to the Right Addresses?

Return to Sender may be a great song, but it's not something you want to see on mail you've sent out for delivery, especially if you happen to be Medicare. Unfortunately, that's been happening to...

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...

Rate of Americans Without Health Insurance Dropped Slightly in January

The number one goal of the Affordable Care Act was to reduce the number of uninsured.  So a Gallup poll released Jan. 23 is at least preliminary good news for the Obama administration.  The...

OIG Says Placement Fees OK for Two Senior Residential Communities

A residential community paying a fee to a placement agency for referring new senior residents raises some concerns over potential anti-kickback statute violations, but the actual arrangement...

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...

MedPAC Targets Post-Acute Care Reforms

MedPAC wants a home health readmissions penalty.

Meaningful Use Hospital Public Reporting Performance Should Be Encouraging

Nearly 80 percent of hospitals participating in the meaningful use program between 2011 and 2013 chose to report some of their health data to a public registry or agency electronically, according...

Prior Health Coverage Indicator Of Better Health For Medicare

Having health insurance before enrolling in Medicare is a good indicator that individuals will enter the program healthier and require less costly care, according to the Government Accountability...

Upcoming Year to Be a Wild One for Health Insurance, Experts Agree

I attended a great Bloomberg BNA event today focused on the health insurance outlook for 2014. Panelists, including Joel Ario from Manatt, Dan Durham from AHIP, Timothy Jost from Washington 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...

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...

Health Payers Will Soon Imitate Supermarkets, Policy Analysts Say

Health insurers in coming years will take a page from supermarkets and offer discounts to their members in exchange for personal information, policy advisors predicted Jan. 9 at an executive...

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...

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,...

CMS Proposes Crackdown on Fraud in Medicare Part C and Part D

A recent CMS proposed rule would require Medicare Advantage plans and Part D sponsors to report and return any overpayments within 60 days of identifying them. Failing to return an identified...

HHS Wants Health Plans to Show Compliance with Electronic Transmission Standards

The Department of Health and Humans Services published a proposed rule in the Jan. 2 Federal Register that would require health plans to certify their compliance with electronic data transmission...

Dissatisfaction with Dropped Slightly in December

The uninsured were slightly less dissatisfied with the federal health insurance marketplace website,, in December than they were in the two months prior, according to a Gallup poll...

Insurance Exchange Problems Among Top Challenges for HHS

Problems with the state and federal health insurance exchanges are among the top management challenges facing the Department of Health and Human Services, according to a recent report from the...

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...

Five Million Likely Uninsured Due To State Decisions Not To Expand Medicaid, Kaiser Says

Nearly five million poor uninsured adults will not have health insurance in 2014 because their state has chosen not to expand Medicaid coverage as allowed under the Affordable Care Act, according to...

Parallel Review Expands. But Will It Get More Participants?

FDA and CMS are expanding a parallel review pilot program for two years.

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...

Health Insurers Still Experiencing High Error Rates for Enrollment Files

While problems for consumers using the federal website are being reduced, enrollment files transmitted to health insurers still have a high rate of errors, which could mean people who...

About 1.4 Million Determined Eligible for Medicaid/CHIP in October, CMS Says

While has had problems getting up and running, more than 1.46 million people have been determined eligible to enroll in Medicaid or CHIP in October through state Medicaid and CHIP...

More Hospitals Will Get Penalized Under VBP in 2014. This is a Good Thing.

More hospitals being penalized under value based purchasing in 2014 isn't necessarily a bad thing.

CMS Issues Guidance on Tricky Meaningful Use Requirements

The Centers for Medicare & Medicaid Services issued guidance to health-care providers highlighting three requirements of Stage 2 of the meaningful use program: clinical summary, patient...

IRS Releases Final Rule Governing ACA Fee On Health Insurers

The IRS has released a final rule implementing a provision of the Affordable Care Act imposing billions of dollars of fees on health insurers—which insurers want repealed. The provision was added...

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...

ZPICs Are Performing Well, But They Could Be Doing Even Better, GAO Says

Zone program integrity contractor (ZPIC) may be an unwieldy term, but the program has been anything but, generating $250 million in savings for the Medicare program in 2012, according to a recent ...

Consumer Coalition Recommends Policies for Future of Health IT Incentive Program

A coalition of more than 50 consumer, patient advocacy, and labor groups Nov. 20 released a set of principles for improving care coordination among health-care providers they hope will influence...

Nearly 93 Percent of Children Have Health Insurance, Report Says

The economic downturn has not caused more children to become uninsured, according to a report released Nov. 20 by the Georgetown University Center for Children and Families. The report found...

When Is a Patient Considered “Admitted” to a Hospital?

Hospitals and CMS disagree on the new "two-midnight" policy Fixes Causing Problems with Private Companies

The head of the online private health insurance marketplace eHealth recently sent a letter to President Obama asking for a new way to offer federally subsidized health insurance plans on his...

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...

Actuaries Warn of Consequences of Extending ACA Open Enrollment Or Delaying Individual Mandate

Delaying implementation of the Affordable Care Act’s individual mandate or extending the open enrollment period for obtaining coverage could have negative consequences for health insurance coverage...

Department of Justice Lowers the Boom on Johnson & Johnson

Looking to avoid untoward government attention? If you're a drug manufacturer, make sure you don't market any of your drugs for non-FDA approved purposes and then bill Medicare or Medicaid.

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...

CBO Reduces Savings Garnered by Increasing Medicare Eligibility Age

A pot of Medicare money that could have been used to help pay for a permanent physician pay fix has mostly evaporated. The Congressional Budget Office Oct. 24 issued an analysis saying that...

OIG Report May Signal More Trouble for Physician-Owned Distributorships

Physician-owned distributorships (PODs) are once again on the receiving end of bad news, this time from the HHS Office of Inspector General, which recently released a report examining spinal...

Got Medigap? It’s Gonna Cost You, and it’s Gonna Cost Medicare.

Medicare spends more on beneficiaries with Medigap than those with traditional Medicare coverage. This doesn't bode well for reducing spending.

Is it Time to Increase Investments in Health Care False Claims Act Cases?

If you invested a dollar into a project, and got $20 back, that would be a pretty phenomenal return, right? Well, that's exactly the return on investment generated by health care False Claims Act...

News Flash: Medicare Payments to Dead People May be Improper

Improper payments have long been the scourge of Medicare, and never more than when the money is going to dead people. New legislation may help ease the problem, according to a recent Congressional...

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,...

OIG Compliance Reviews Continue to Uncover Hospital Overpayments

A coordinated effort from the HHS Office of Inspector General to evaluate Medicare compliance at hospitals across the country has hit the jackpot over the past months, uncovering $6.3 million in...

CMS Should Remove Social Security Numbers From Medicare ID Cards, GAO Says

The Centers for Medicare & Medicaid Services should remove Medicare beneficiaries' Social Security numbers from program identification cards to guard against identify theft and fraud, the...

Is CMS Asleep at the Wheel When it Comes to Sleep Studies?

Were Medicare contractors asleep at the switch in 2011 when they paid out $17 million for sleep study claims that were inappropriately billed? It might be a reasonable opinion to have after...

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...

Assistance Groups Using Federal Marketplace Delays for Education Efforts

In an Oct. 8 press briefing, groups that are conducting outreach and enrollment assistance to get people signed up for health insurance under the Affordable Care Act put the best face on the delays...

Is Extrapolation a Good Way to Determine Medicare Overpayments?

Extrapolation may be a common statistical tool, but the University of Miami Hospital says it's not a fair one. A report from the HHS Office of Inspector General, extrapolating from a 200 claim...

Where's the Best Location for an ACO?

A new study shows ACOs are forming in areas of the country where providers are already becoming integrated.

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...

Congressional Budget Impasse Threatens Medicare Doc Fix, Lobbyist Says

The shutdown of the federal government due to the fiscal impasse over the budget threatens to derail action on a permanent Medicare physician pay fix, and might even jeopardize a short-term fix,...

Senate Finance Committee to Look at Health Insurance Exchanges

A Senate Finance Committee staffer said the committee will be focused on operational issues surrounding the health insurance exchanges for the remainder of 2013, during a session I attended at...

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...

Is the Government Coming After Skilled Nursing Facilities?

If you're operating a skilled nursing facility (SNF), you can expect an increase in medical record reviews from a myriad of government agencies and contractors, according to a webinar I recently...

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...

FDA Finally Releases Unique Device ID Rule

FDA releases long-awaited unique device ID rule.

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...

HHS Designates Four Types of Health Insurance Marketplaces

Faced with greater-than-expected opposition from states to setting up their own online health insurance marketplaces under the Affordable Care Act, the Department of Health and Human Services has...

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...

Federal Contractors Testify They Will Be Ready for Affordable Care Act Open Enrollment Oct. 1

Four health information technology contractors working on the online health insurance marketplaces that will be run by the federal government testified Sept. 10 at a congressional hearing that...

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...

Is CMS Not Fixing RAC-Identified Payment Vulnerabilities?

CMS got a rap on the knuckles in a recent OIG report , which said the agency is not evaluating the success of corrective actions it has taken to close Medicare vulnerabilities to improper payments....

Administration Releases Final Rules Before Health Insurance Marketplaces Open

As the Obama administration heads into the final stretch before the online health insurance marketplaces open for enrollment Oct. 1 under the Affordable Care Act, agencies released a final flurry of...

$450 Million in Budget Savings Skipped Due to Lack of Fraud Funding

Congress is leaving $450 million in deficit savings on the table by not fully funding the Health Care Fraud and Abuse Control (HCFAC) account, according to a recent report from the Office of...

Medicare Spending Growth Has Slowed, But CBO Doesn’t Know Why

Medicare spending growth has slowed considerably in recent years. CBO just doesn't know why.

Get Ready for a Review of the DME Competitive Bidding Program

While certainly not an everyday occurrence, sometimes Congress actually gets things done. As an example, a congressional request has led the OIG to conduct a limited, four-state review of...

Questionable Billing May Have Cost Medicare $425 Million in 2011

A weakened claims-processing system combined with limited oversight may have cost Medicare $425 million in inappropriate claims payments in 2011 to diabetes-test strip (DTS) suppliers, according to...

Use of Antipyschotics Drops in Nursing Homes, CMS says

A national campaign to cut the use of antipsychotic drugs in nursing homes appears to be working, the Centers for Medicare & Medicaid Services said Aug. 27. Nursing homes are using...

Medical Residents Left Out of New CMS Hospital Admission Policy

New CMS policy leaves medical residents unable to admit patients.

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...

Only 27 Percent of Young Adults Aware of Insurance Marketplaces

While more young adults are taking advantage of an Affordable Care Act provision allowing them to remain on their parents' health insurance plans until they are 26, there is a long way to go before...

Physician Participation in Medicare is Growing, HHS Says

As Congress prepares to take further action to create a new Medicare physician payment system, the Department of Health and Human Services says physician participation in Medicare is growing. HHS...

HHS Awards $67 Million in Grants to Enroll People in Health Insurance

With less than seven weeks before the crucial online health insurance marketplaces are set to open under the Affordable Care Act, the Department of Health and Human Services Aug. 15 announced $67...

Are Critical Access Hospitals in Compliance with Medicare Certification?

If Congress were to get rid of certain exemptions for critical access hospital, the vast majority of critical access hospitals (CAHs) would not have been in compliance with location requirements...

McDermott Asks CMS To Resolve Backlog of Stark Submissions

House Ways and Means Health Subcommittee ranking minority member Jim McDermott (D-Wash.) has asked the Centers for Medicare and Medicaid Services to submit a written plan for revising its...

Did CMS Solve Its Observation Status Problem?

A new  Medicare policy is intended to curb the use of observation status. But will it solve the problem? Hospitals and patient advocates don't think so.

“You Have Been Wronged! Do You Have an Attorney?” Perils of Predicting Case Outcome

Attorneys are often asked, “Do you think I’ll win?” In answer, they could cite a June 4, 2013 , court of appeal ruling to show that even members of Congress, at a hearing I attended five years...

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...

Are Self-Referring Providers Driving Up Medicare Costs?

Self-referring providers have dramatically expanded their use of an expensive prostate cancer treatment over the last few years, and Medicare costs have been rising as a result, according to a...

Finance Committtee to Hold July 31 meeting on Medicare Physician Pay Fix

Fixing Medicare's physician payment system will receive attention from the House and Senate this week. The Senate Finance Committee will hold an informal meeting of its members July 31st to discuss...

CMS Halts New Medicare Provider and Supplier Enrollment in Three Cities

What do Miami, Chicago, and Houston have in common? As of July 30, the three cities and some surrounding counties will all be under a six-month moratorium from CMS for the enrollment of certain...

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.)...

Not All Pioneer ACOs Have Found Success

Results from the first year of the Pioneer ACO program are decidedly mixed.

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...

Senior Citizens Continue to Take a Bite Out of Health Care Fraud

Senior citizens continue to be an effective bulwark against fraud, as Senior Medicare Patrol activities led to $72,000 in actual Medicare and Medicaid recoveries in 2012, a 279 percent increase...

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...

Self-Referring Providers Continue to Take a Toll on Medicare

Self-referring providers in 2010 referred biopsy services at a higher rate than non self-referring providers, resulting in an additional $69 million in Medicare payments, according to a GAO report...

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...

Is CMS Having Problems Collecting Medicare Overpayments?

CMS contractors reported uncollected Medicare overpayments of $543 million in fiscal year 2010, but detailed overpayment information was only available for seven out of the 39 affected contractors,...

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...

House Panel Releases New Medicare Physician Payment Fix Proposal

House GOP leaders have taken another step toward repealing the sustainable growth rate formula feature of Medicare’s current physician payment system and replacing it with one based on quality of...

Physicians Continue to Say Yes to Electronic Health Records

In ever growing numbers, physicians are embracing electronic health records (EHR) and incorporating more sophisticated technology into their practices, according to a recent report to Congress....

HHS Finalizes Exemptions From Health Insurance Penalties

People who can not afford to buy health insurance, or those who are ineligible for Medicaid based on a state's decision not to expand its program under the health care reform law, will not be fined...

Legislation Would Reward Seniors For Improving Their Health

A bipartisan group of House and Senate lawmakers are touting a new bill that they say for the first time would allow Medicare to reward seniors for improving their health. The Medicare Better...

Why Is Medicare Paying for Prescriptions Ordered by Massage Therapists?

Massage therapists, athletic trainers, and dieticians share one thing in common: they cannot order Medicare Part D prescription drugs. Unfortunately, that message has not registered with Medicare,...

Are Physicians Using Their Prescribing Powers Appropriately?

Some physicians may be abusing their prescribing powers, ordering unnecessary and even dangerous drugs for patients, a recent report from OIG said. The report identified 736 general-care...

Health Insurers to Pay $500 Million in Medical Loss Ratio Rebates for 2012

More than 8.5 million health insurance consumers will get the benefit of over $500 million in rebates under the medical loss ratio (MLR) requirement of the Affordable Care Act, the Department of...

Is It Time for the Public to See Medicare Claims Data?

The public would have a chance to peek behind the curtain of Medicare claims data, if a recently introduced bill passes Congress. . The Medicare Data Access for Transparency and Accountability...

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...

HHS Proposed Rule Would Allow `Unbanked' To Enroll in Health Coverage

Jackson Hewitt Tax Service is claiming credit for inducing the HHS June 14 to propose requiring health insurers to allow enrollees in the online marketplaces that open Oct. 1 to be able to pay for...

FDA Tries Updating Device Guidance, Take Two.

Consumer and industry opinions differ on what to include in a new FDA guidance on if a change to a device warrants a new marketing application.

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)...

Stakeholders Weighing In On House GOP Medicare Physician Pay Fix Plan

Comments are coming into the House Energy and Commerce Committee about its plan to revamp Medicare’s physician payment system as the panel continues to refine its proposal in hopes of having...

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...

Medicare's Financial Future Uncertain, CMS Acting Actuary Says

Medicare’s Trustees reported May 31 that the program’s Part A Trust Fund would be financially solvent until 2026, two years later than estimated last year, but the Acting Chief Actuary for the...

Data Mining Final Rule for MFCUs Might Not Have Large Impact

A recent final rule from OIG permitting MFCUs to use federal funds to pay for data mining technology may not end up having a huge impact on fraud prevention, according to an attorney I talked to...

Final Rule Boosts Rewards for Participating in Wellness Programs

Beneficiaries got a gift from the administration in the form of increased financial incentives for participating in wellness programs offered by their group health plans, part of a final rule from...

Are House Committees Parting Ways Over Medicare Payment System Revamp?

With the release May 28 of a third legislative draft that would revamp the Medicare physician payment system and repeal the sustainable growth rate formula, the House Energy and Commerce...

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”...

House Republicans To Release Legislative Langauge On Doc Fix Memorial Day Week, Pitts Says

House Republicans are moving closer to their goal of having a Medicare physician payment fix on the floor by the August congressional recess. House Energy and Commerce Health Subcommittee Chairman...

HHS Receives Over 830 Letters of Intent for `Navigators'

The Department of Health and Human Services has received more than 830 nonbinding letters of intent from organizations that plan to apply for $54 million in federal grants to be "navigators" helping...

Is Congress Undermining The IPPS? GAO Thinks So.

Legislative modifications to the hospital inpatient prospective payment system (IPPS) have undermined its goals,  according to GAO.

Why the Sunshine Act Just Might Violate the First Amendment

While reporting requirements under the Sunshine Act have yet to kick in, the payment transparency program is already facing allegations that a specific provision may violate the First Amendment. The...

Bloomberg BNA Report on the BIO 2013 International Convention

A  report that collects 10 articles that I wrote covering the BIO International Convention in Chicago last month is available by clicking on the highlighted...

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...

Practical Guidance is the Name of the Game for OIG Exclusion Bulletin

I spoke with an OIG official this week who told me that updated special advisory bulletin on exclusions was intended to give providers more practical guidance than the original bulletin did when it...

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...

HHS Issues Streamline Applications For Health Coverage

The Centers for Medicare & Medicaid Services this week addressed criticism of the lengthy application forms they had proposed for enrolling uninsured people in health coverage.  On April 30 the...

Impact of Sequestration on Life Sciences--FDA Can't Travel(1)

The effects of sequestration on the Food and Drug Administration were apparent in a particular way at the BIO 2013 International Convention in Chicago that I covered—FDA officials didn’t have the...

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...

Sebelius Defends Using Prevention Fund for ACA Promotion

With the release of the Obama administration's fiscal 2014 budget proposal, it has become clearer how the Department of Health and Human Services has been funding implementation of the Affordable...

Senate Finance Committee To Hold April 23 Nomination Vote For Tavenner

The Senate Finance Committee April 23 will vote on the nomination of Marilyn Tavenner to be administrator of the Centers for Medicare & Medicaid Services. If the nomination is approved, as...

FDA To Try Again With Investigational Devices

FDA will replace a 2011 draft guidance on investigational devices after industry backlash.

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...

Thoughts on the Supreme Court, Door Knobs, and Genes

A speaker at a recent gene patent conference I covered suggested that the Supreme Court has of late been retreating back to the ideas of an 1850 case about door knobs.

With Budget, Obama Takes MedPAC’s Advice

President Obama's FY 2014 budget request takes into account recommendations made by MedPAC.

CMS Budgets $5.8 Billion For Exchange Grants For Three Years

Under the fiscal 2014 budget proposal released April 10, the Centers for Medicare & Medicaid Services would spend $1.3 billion for grants to states to set up online exchange markets to sell...

Moving from Discretionary to Mandatory Spending for HCFAC

President Obama's April 10 budget proposal for fiscal year 2014 includes a 0.3 percent decrease in discretionary spending ($311 million) for the Health Care Fraud and Abuse Control account from...

Obama Proposes $400 Billion In Health Care Spending Cuts

As expected, President Obama April 10 proposed a fiscal 2014 budget plan that would trim about $400 billion from federal health care spending, the vast majority coming from Medicare. The biggest...

Tavenner Could Soon Be Approved by Senate As CMS Administrator

The Centers for Medicare & Medicaid Services could soon have its first Senate-approved administrator since 2006. CMS acting administrator Marilyn Tavenner is scheduled to appear before the...

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...

First ACO Results Due This Summer, CMS Official Says

The first results of the Pioneer accountable care organization initiative will be available this summer, a Centers for Medicare & Medicaid Services official told Congress March 20. Richard...

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...

Will Medtronic's New Device Be A Standard-Bearer?

Medtronic is taking a chance with FDA and CMS's new parallel review pilot.

J.D. Power and Associates Survey Finds Consumer Interest in Health Insurance Exchanges

The online health insurance exchange markets that will open for enrollment Oct. 1 under the Affordable Care Act are generating interest among consumers, marketing information company J.D. Power and...

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...

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...

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...

Gene Patent Outlook Now Clearer in Australia, U.S. Still Waits

In Australia, things are clearer now for owners of gene patents than they were a week ago, while U.S. gene patent owners are still anxiously waiting for the April 15 oral arguments to begin before...

Providers Preparing for Sequestration Cuts, Attorney Says

Medicare providers already are taking steps in anticipation of sequestration cuts that are likely to occur March 1, including scaling back programs, eliminating positions and postponing...

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...

Medicare Physician Payment to be cut 25 Percent in 2014, CBO Says

Like a broken record, physicians again are facing a Medicare reimbursement cut unless Congress intervenes. The Congressional Budget Office said Feb. 5 that physicians' reimbursement will be reduced...

Lawmakers Introduce Device Tax Repeal Bills. Again.

Lawmakers introduce device tax repeal bills in the House and Senate.

IRS Rule Could Leave Some Families Without Affordable Health Insurance or Subsidies

The Internal Revenue Service (IRS) disappointed consumer groups and unions when it released a final rule Jan. 30 that could leave some families without  affordable health insurance coverage or...

Is the Sunshine Act Too Much of a Burden for the Health Care Industry?

A number of health care attorneys have told me that providers and drug and device manufacturers can expect significantly expanded administrative burdens courtesy of the recently released "Sunshine...

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 ...

Hatch Says Medicare Eligibility Age Should Be Set At 67

Senate Finance Committee ranking minority member Orrin G. Hatch (R-Utah) wants Medicare's eligibility age hiked from 65 to 67, saying it must keep pace with increases in longevity in the...

PCORI Wants to Change Research to Focus on Patient Needs

PCORI director Joe Selby talks about how the organization wants to make comparative effectiveness research more patient-centered.

Hatch, Alexander Introduce Bill To Repeal Individual Mandate In ACA

Senate Finance Committee Ranking Member Orrin Hatch (R-Utah) and Senate Health, Education, Labor and Pensions Committee Ranking Member Lamar Alexander (R-Tenn.) Jan. 22 introduced legislation...

Time to Get Ready for Larger Penalties for HIPAA Violations

Health care providers are now facing significantly higher penalties for HIPAA violations, courtesy of an HHS final rule released Jan. 17. The HIPAA Enforcement final rule, which was part of an...

NAIC Calls For State-By-State Health Reinsurance Pools

The federal government should scrap a proposal to create a national health reinsurance pool and rely instead on state-by-state collections for the program, the organization that represents state...

Hike In Medicare Age Won't Dramatically Increase Corporate Health Care Costs, CEO Says

Businesses already are developing strategies to keep their workers productive for longer periods of time, so raising Medicare's eligibility age may only incrementally increase health care costs for...

Is Anyone Watching Over Community Mental Health Centers?

Effective oversight of community mental health centers (CMHCs) is lacking, and Medicare might be wasting taxpayer money as a result, the OIG said in a recent report. A review of nine Medicare...

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.

Hospitals Concerned About Series of Budget-Cutting Bills Moving Through Congress

Federation of American Hospitals President Chip Kahn says he is worried that a series of plans that may be considered by Congress and the White House in 2013 to reduce federal spending may be worse...

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...

Eighteen States and D.C. To Create State-Based Exchanges

Eighteen states and the District of Columbia have made the commitment to open state-based exchanges through which individuals and small businesses can purchase health insurance under the Affordable...

Europe Welcomes Unitary Patent Cost Savings but Worries about Enforcement

Europe looks like it will finally have a unitary patent system that will reduce the costs of a patent. But the plan has caused concerns about the sudden speed toward approval and the way in which the patents will be enforced

AHA Finds Medicare Is Spending More on Sicker Patients

New report finds evidence that Medicare patients are getting sicker, and it's not just because of coding changes.

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...

Raising Medicare Eligibility Age Could Be Part Of Budget Deal

Raising Medicare's eligibility age could become a key component of a deal between the White House and Congress to avert the so-called fiscal cliff, but critics say raising the age would shift costs...

Fate of Medicare Physician Pay Fix Likely Linked To Fiscal Clliff Negotiations

It appears the fate of a Medicare pay cut for physicians rests on when and if the White House and congressional negotiators reach agreement on a plan to avert the so-called fiscal cliff, the package...

To Patent or Not to Patent May Be the Question, Attorneys Say

At a conference I attended recently, a session followed up on an idea of companies looking into the possibility of trade secret protection for their inventions rather than patents.

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...

Attorneys Ears Perk Up at Millions of Dollars in Potential New Revenue from Patent Term Adjustments

It was interesting to hear attorneys at a recent biotech conference I attended get very excited about the millions of additional dollars a patent term adjustment can bring in.

Will the Medicare Fraud Strike Force Be Expanding Soon?

Are we likely to see the Medicare Fraud Strike Force expand to additional cities in the near future? According to Sam G. Sheldon, deputy chief of the fraud section in the DOJ's criminal division,...

FAH Urges Congress To Delay Or Cancel Sequestration Cuts

The Federation of American Hospitals is urging Congress to postpone or delay Medicare spending cuts associated with the sequestration law, saying hospitals will be forced to layoff thousands of...

With Presidential Election Over, More ACA Rules Expected

With the presidential election now in the rear-view mirror, the Obama adminisratiion is likely to quickly begin issuing several crucial rules governing the implementaiton of the Affordable Care Act....

NIH Exercising “March-In” Rights—Is the Fifth Time the Charm?

The National Institutes of Health has denied four petitions to exercise its “march-in” rights under the Bayh-Dole Act. I wrote a number of stories on the fourth, the Fabrazyme petition. On   Oct....

Stark Self-Disclosure Agreements Reveal Lengthy Path to Resolution

If you're planning on entering the CMS self-referral disclosure protocol (SRDP), be prepared to wait. I recently obtained the 10 settlement agreements that have been reached under the SRDP in...

Health Insurance Subsidies Likely to Cost More Than Forecast, Former CBO Director Warns

The projected cost of the subsidies provided by the Affordable Care Act to low- and moderate-income people to make health insurance affordable has escalated 24 percent since the law was enacted in...

Medicare Home Health Reimbursement Could Be Cut In Deficit Deal, Dombi Says

Medicare reimbursement to home health agenices could be targeted for reduction as part of sweeping budget deficit deal that may be consisdered by Congress in 2013, according to Bill Dombi, vice...

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...

European Drug Approval Agency Appears to Get Back Its Parliament’s Trust

The European Medicines Agency, the European equivalent to the FDA for drug approval, has evidently convinced the European Parliament that it has its act together as far as conflicts of interest in the agency are concerned.


Seniors Would Pay More Under Premium Support, Kaiser Says

Premiums would have risen for the majority of beneficiaries if Medicare had been operating as a premium support program in 2010 because most of them would have been in areas where their current...

“You Have Been Wronged! Do You Have an Attorney?” Problems in Predicting Case Outcome

Attorneys are often asked, "Will I win this case?" The correct answer is usually, "It depends." But attorneys could also cite a recent court case involving medical research where even members of Congress got it wrong at a hearing I attended.

Trouble Brewing for Medicare's Predictive Modeling Program

Two Republicans Senators continued their quest to gather information on CMS's anti-fraud predictive analytics program, sending a letter to the agency this week calling for the delivery of a report...

Senate Republicans May Have Difficulty Repealing ACA Using Reconcilation, Former GOP Aide Says

A former Republican aide on the Senate Finance Committee says Republicans' promise to repeal the Affordable Care Act next year using the budget reconciliation process may run into difficulty because...

FDA Head Says Sequestration Will Hit Agency's Key Personnel

The Food and Drug Administration Commissioner said at a meeting I attended that if the"sledgehammer of sequestration" takes effect FDA would suffer significant loss of critical personnel.

Will Affordable Care Act Health Insurance Exchanges Lead to Demise of Employer-Sponsored Coverage?

Will the health insurance exchange markets that will be created in all states in 2014 under the Affordable Care Act primarily be a new channel for employers to purchase coverage, as the Obama...

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...

Changes Coming To ACA Even if Obama Relected, Former GOP Aide Says

Republican presidential nominee Mitt Romney will attempt to repeal the health care reform law if he is elected president, but the law may be changed in some significant ways even if President Obama...

Are Hospitals Doing Enough to Secure Electronic Health Records?

According to a  recent DOJ-HHS letter, hospitals are not doing enough to prevent electronic health records from being used to defraud Medicare and will likely face increased investigations and...

Hospitals Could Face More Medicare Cuts Next Year, Attorney Says

Hospitals may find their Medicare reimbursement on the chopping block again in 2013 as Congress and the White House look for ways to cut the federal budget deficit, according to a California...

States Choose Small Group Plans As Benchmarks For Essential Health Benefits

A major requirement of the Affordable Care Act is that most fully-insured individual and small group health insurance plans must offer a comprehensive set of benefits called "essential health...

House Energy and Commerce Committee OKs Bill Removing Commissions From Medical Loss Ratio

Washington lobbyists will tell you that insurance agents are among the most powerful forces in American politics, since they come close to having an office on every corner.  That influence is in...

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...

ACA Coverage Expansion Could Be Delayed By A Year, Scully Says

Former Centers for Medicare & Medicaid Services Administrator Tom Scully believes that if President Obama is reelected, there is a chance the coverage expansion in the Affordable Care Act...

Could Political Oppostion To ACA Be Reason Some States Are Having Trouble Implmenting Exchanges?

A witness before a House panel Sept. 12 said political oppostion to the Affordable Care Act, not a lack of rulemaking from the Department of Health and Human Services, is the reason some states have...

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...

Institute of Medicine Report Calls For Changes to U.S. Health Care System

The Institute of Medicine released a 382-page report Sept. 6 that largely says what has been agreed on for some time now -- that the U.S. health care system is far too expensive and wasteful to be...

Medicare Providers Should Prepare For Cuts in 2013 No Matter Who is President, Consultant Says

Health care has been quite prominent in the presidential race, with both parties setting out their competing visions for the health care system. Medicare providers, however, should prepare for...

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...

HHS Moves to Bar Illegal Aliens Granted Amnesty From High-Risk Pools

The Department of Health and Human Services made it clear Aug. 28 that young illegal aliens who were granted amnesty in June by President Obama will not be able to take advantage of the temporary...

GOP Platform Seeks Medicare Voucher Program, ACA Repeal

Delegates to the Republican National Convention Aug. 28 approved their party's platform for 2012, and while platforms are not specifically adhered to by candidates running for public office, the...

Time To Suspend 60-Day Repayment Rule? Trade Groups Say Yes

Industry trade groups recently called for suspending the 60-day repayment rule for any provider who enters into the OIG's provider self-disclosure protocol. A number of trade groups, including the...

HHS Awards Eight States $766.5 Million in Grants To Build Exchanges

The Department of Health and Human Services continues to push forward in its drive to entice states to establish “state-based” health insurance exchanges, announcing another $766.5 million in grants...

Majority of Community Mental Health Centers Engaged in Questionable Billing, OIG Says

Claims submissions from community mental health centers (CMHCs) are on the OIG's radar screen, with a recent report detailing that 52 percent of CMHCs met or exceeded the claims threshold for...

FDA Aims To Smooth Premarket Review process

FDA hopes two draft guidances will increase premarket review times and lead to a better use of agency resources.

Industry Groups Want More Time to Comply With Sunshine Act

Industry trade associations are looking for more time to comply with the requirements of the Physician Payments Sunshine Act, according to a recent letter sent to CMS. Specifically, the four...

HHS Issues Final `Blueprint' for Health Insurance Exchanges

The Department of Health and Human Services Aug. 14 released its final “blueprint” for states to use to apply to operate their own online health insurance “exchange” markets in 2014 under the...

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...

Studies Lay Groundwork for Congressional Debate on Health Care Costs

New England Journal of Medicine studies lay the groundwork for what could be the debate in Congress over controlling rising health care costs.

OIG Uncovers Medicare Overpayments for Breast Cancer Drug

Two Medicare contractors overpaid providers $2.2 million for the breast cancer drug Herceptin, the OIG said in two recent reports, and it's time to get that money back. The OIG looked at a  sample...

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...

Health Insurers Say MLR Limits Worthwhile Expenditures

On Aug. 1 health insurance plans that didn’t meet new medical loss ratio (MLR) rules had to refund about  $1.1 billion to individuals and/or employers and AHIP—the insurance industry lobbying...

HHS Will Be Ready to Operate Federal Exchanges by 2014

The Department of Health and Human Services will be ready to operate federal online health insurance exchange markets required by the reform law by 2014, the acting director of the office that is...

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...

Hospitals Not Reporting Adverse Event Data, and Patients May Be Suffering

Hospitals are not identifying and reporting the vast majority of adverse events happening during medical treatment, and patient safety is being impacted, according to a recent report from the OIG....

Demise of Small Group and Solo Physician Practices Bodes Ill for Physician-Patient Relationship, Panel Told

Will small group and solo physician practices still be around in another decade?  The trend is toward increasing numbers of doctors abandoning small practices to align themselves with hospitals or...

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...

Predictive Modeling Is a Crucial Tool for Fighting Health Care Fraud, Association Says

Congressional support and funding for Medicare and Medicaid predictive modeling analytics is a must in the battle against health care fraud, according to recommendations the National Health Care...

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.


House Republicans, Democrats Claim Momentum From Supreme Court Ruling

Both Republicans and Democrats are claiming momentum for their agenda of either repealing PPACA or proving its worth to the country.

Not Quite Full Speed Ahead

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

Business Leaders Concerned Health Care Costs Will Rise Under PPACA

A panel of business leaders were not timid in their opposition to PPACA, arguing it will not only raise their health care costs but will also lead to a reduction in new jobs, during a House...

House To Again Vote on Repealing Reform

The House will vote July 11 on legislation to repeal the health care reform law

HHS Announces New Exchange Grants and Guidance For States

In an attempt to spur states to move ahead on setting up their own internet-based health insurance exchange markets by 2014, the Department of Health and Human Services June 29 issued guidance...

More Legal Challenges May Be on the Way for the Affordable Care Act

After months of waiting, the U.S. Supreme Court June 28 ruled that the Patient Protection and Affordable Care Act is constitutional and its implementation can proceed. That should end the legal...

It’s High Time for CMS to Streamline Program Integrity Efforts, Hospital Association Says

Duplicate audits from program integrity contractors and an increasing disregard for the medical expertise of physicians are making it essential for CMS to revamp and streamline anti-fraud and...

Health Insurers Have Low-Key Reaction to Supreme Court Ruling

Associations that represent health insurers reacted with low-key statements after the U.S. Supreme Court ruled June 28  that the Patient Protection and Affordable Care Act is largely...

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...

EHRs Are on the Way, But Budgets Are Getting Strained

Hospitals and health systems are making significant progress in setting up electronic health records systems, but money is starting to get tight, KPMG said in a recent poll.

Insurers Will Pay $1.1 Billion in Medical Loss Ratio Rebates for 2011

Health insurers will pay $1.1 billion in rebates that will benefit 12.8 million policyholders by Aug. 1, the Department of Health and Human Services announced   June 21. Insurers are required...

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...

NAIC Moving To Limit Stop-Loss Coverage for Small Companies

The National Association of Insurance Commissioners (NAIC), a Kansas City-based organization that represents state insurance regulators, is moving to update its model law governing “stop-loss”...

End In Sight for HHS Privacy and Security Pilot Program

An HHS privacy and security audit pilot program is expected to end by December, an HHS Office of Civil Rights official said during a conference I attended last week. OCR began the program in June...

Spending on Prescription Drugs and Physcian Services to Rise Under Reform Law, CMS Says

With everyone waiting on the edge of their seats for the U.S. Supreme Court decision on the constitutionality of the health care reform law, the Centers for Medicare & Medicaid Services June 12...

Hospital Group Says It’s Time to Simplify Health Care Regulations

Medicare and Medicaid regulations have grown increasingly bulky and burdensome, a hospital trade group recently said, and it's time for Congress to step in and make things right.


CBO Says Health Spending Eventually Will Slow Even Without Additional Federal or State Action

Health care spending growth continues to outstrip that of the overall economy, but according to a new Congressional Budget Office report I wrote about this week, spending is expected to slow...

45 Payers, 75 Practices to Participate in Bonus Payment Demonstration Program to Coordinate Care

Forty-five commercial, federal, and state insurers in seven markets finalized memorandums of understanding with the Centers for Medicare & Medicaid Services June 6 to participate in a demonstration program under which they will pay primary care practices bonus payments to better coordinate care for their patients, CMS announced.


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.

Providers Say Chronic Disease Management Programs Could Save Medicare Billions

Is it possible for health care providers to manage chronic diseases such as diabetes, saving the health care system tens of billions of dollars or more annually?

PPACA Or No, Accountable Care is Here to Stay

No matter what happens with the health reform law, the concept of “accountable care” isn’t going away.

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.