Alek Pivec at King & Spalding

PRRB Updates Rules and Mandates Electronic Filing Effective November 1, 2021

On June 16, 2021, the Provider Reimbursement Review Board (PRRB) issued proposed changes to its rules and an order requiring all submissions for new and/or pending appeals to be filed electronically using the Office of...more

6/25/2021 / Amended Rules , Electronic Filing , Filing Deadlines , Inpatient Prospective Payment System (IPPS) , PRRB

Federal Court Invalidates Medicare DGME Rule that Penalizes Hospitals for Training Fellows

On Monday, May 17, 2021, Judge Timothy Kelly of the United States District Court for the District of Columbia issued a decision setting aside a regulatory formula CMS has adopted to compute Medicare DGME payments to...more

5/28/2021 / Centers for Medicare & Medicaid Services (CMS) , Graduate Medical Education , Medicare , Teaching Hospitals

CMS Issues Medicare IPPS and LTCH Proposed Rule for FY 2021

On April 27, 2021, CMS issued the fiscal year (FY) 2022 proposed rule for the hospital inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) prospective payment system (the Proposed Rule). Among...more

Federal Court Affirms Denial of Medicare Payment for Inpatient On-Call Services to Critical Access Hospital

On March 31, 2021, Judge Carl Nichols of the United Stated District Court for the District of Columbia issued a decision upholding CMS’s denial of reimbursement to a California Critical Access Hospital (CAH) for compensation...more

4/8/2021 / Centers for Medicare & Medicaid Services (CMS) , Consolidated Appropriations Act (CAA) , Denial of Insurance Coverage , EMTALA , Medicare , Medicare Administrative Contractors (MAC) , Motion for Summary Judgment , Payment Systems , Physician Medicare Reimbursements

CMS Finalizes the Physician Fee Schedule Rule for Calendar Year 2021

On December 2, 2020, CMS issued a final rule updating the payment policies and rates for services to be furnished under the Medicare Physician Fee Schedule (PFS) in calendar year (CY) 2021. The final rule includes...more

12/11/2020 / American Medical Association , Centers for Medicare & Medicaid Services (CMS) , Final Rules , Medicare , Medicare Part D , Physician Fee Schedule , Telehealth

HHS to Distribute $333 Million in Performance Incentive Payments to Nursing Homes for Curbing COVID-19 Infections and Deaths

On October 28, 2020, HHS announced that it would distribute $333 million to nursing homes that demonstrated significant reductions in COVID-19-related infections and deaths in September. “These $333 million in performance...more

11/16/2020 / Coronavirus/COVID-19 , Department of Health and Human Services (HHS) , Nursing Homes , Performance Incentives

CMS Issues Medicare IPPS and LTCH Final Rule for FY 2021

On September 2, 2020, CMS issued the fiscal year (FY) 2021 final rule for the hospital inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) prospective payment system (the Final Rule). This article...more

9/11/2020 / Bad Debt , Centers for Medicare & Medicaid Services (CMS) , DSH , Dual Eligibility , EHR , Final Rules , Financial Assistance Policies , Graduate Medical Education , Inpatient Prospective Payment System (IPPS) , Long Term Care Facilities , Medicaid , Medical Reimbursement , Medicare , Medicare Advantage , Patient Prospective Payment System

CMS Issues Instructions for MACs to Adjust Part C Payments for Nursing and Allied Health and Direct Graduate Medical Education...

On August 21, 2020, CMS issued a transmittal (Change Request 11642) instructing Medicare Administrative Contractors (MACs) to recalculate the Part C components of nursing and allied health (NAH) and direct graduate medical...more

9/2/2020 / Centers for Medicare & Medicaid Services (CMS) , Compensation , Medicare Administrative Contractors (MAC) , Medicare Part A , Medicare Part C

D.C. District Court Upholds Price Transparency Rule

On June 23, 2020, Judge Carl Nichols of the United States District Court for the District of Columbia issued a decision upholding CMS’s price transparency rule, which was adopted late last year. The case is cited as American...more

7/1/2020 / Affordable Care Act , American Hospital Association , Appeals , Centers for Medicare & Medicaid Services (CMS) , Executive Orders , Guidance Update , New Rules , Public Health Service Act , Summary Judgment , Third-Party , Transparency

CMS Proposes Retroactive Codification of “Longstanding” Bad Debt Policies in IPPS Proposed Rule

In the Medicare inpatient prospective payment system (IPPS) proposed rule for fiscal year (FY) 2021 (the Proposed Rule), CMS has proposed to amend its existing bad debt regulation to incorporate the agency’s bad debt policies...more

5/26/2020 / Azar v Allina Health Services , Bad Debt , Beneficiaries , Centers for Medicare & Medicaid Services (CMS) , Inpatient Prospective Payment System (IPPS) , Medicare , Proposed Rules

Third Circuit Rules that Clinical Judgments Are Falsifiable; Can Trigger FCA Liability

Last week, the United States Court of Appeals for the Third Circuit held that prognoses of terminal illness submitted in support of hospice claims for reimbursement could be actionable false statements under the False Claims...more

3/17/2020 / False Claims Act (FCA) , Health Care Providers , Healthcare Fraud , Hospice , Medicare , Objective Falsity , Qui Tam

Proposed Budget Would Cut Medicare and Medicaid Funding in FY 2021

On February 10, 2020, the White House unveiled its proposed budget (the Budget) for FY 2021, which would decrease funding for HHS by 10 percent. Medicare and Medicaid would bear the brunt of these cuts. For both programs...more

2/24/2020 / Budget Cuts , Federal Budget , Federal Funding , Health Care Providers , Health Insurance , Hospitals , Medicaid , Medicare , Physicians , Trump Administration

GAO Report Claims 340B Program Needs More Oversight of Hospitals

On January 10, 2020, the U.S. Government Accountability Office (GAO) issued a report claiming that the Health Resources and Services Administration (HRSA) does not use adequate controls to confirm the eligibility of private...more

1/16/2020 / Drug Pricing , GAO , Healthcare , Hospitals , HRSA , Low-Income Issues , Medicare , Non-Profit Hospitals , Section 340B

CMS Publishes Final Rule for CY 2020 Hospital Outpatient Prospective Payment System

n November 1, 2019, CMS posted the final rule establishing the payment rates for the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgery Center (ASC) Payment System for calendar year (CY) 2020...more

Eleventh Circuit Denies Preliminary Injunction for New National Liver Transplant Allocation Policy

On September 25, 2019, the United States Court of Appeals for the Eleventh Circuit affirmed a lower court’s decision to deny a motion for a preliminary injunction to stay the implementation of the new policy for allocating...more

10/4/2019 / Amended Rules , Appeals , Department of Health and Human Services (HHS) , Health Care Providers , Hospitals , Injunctive Relief , Likelihood of Success , Motion To Stay , Organ Transplant Centers , Preliminary Injunctions , Remand

CMS Issues FY 2020 Inpatient PPS and Long-Term Care Hospital PPS Final Rule

On August 2, 2019, CMS issued its annual Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System Final Rule for FY 2020 (the Final Rule). Highlights include...more

8/9/2019 / Affordable Care Act , CEHRT , Centers for Medicare & Medicaid Services (CMS) , Final Rules , Inpatient Prospective Payment System (IPPS) , Inpatient Quality Reporting , Long Term Care Facilities , Medicare , Payment Systems , Psychiatric Hospitals , Wage Index

Florida Hospitals Prevail in Litigation Challenging the Exclusion of Low Income Pool Days from the Medicare Disproportionate Share...

On July 23, 2019, Judge Rosemary Collyer of the United States District Court for the District of Columbia issued an opinion ruling in favor of ten Florida hospitals in their case challenging the calculation of their Medicare...more

7/31/2019 / Centers for Medicare & Medicaid Services (CMS) , Disproportionate Share Adjustments , Hospitals , Inpatient Billing , Medicaid , Medicare

Fifth Circuit Orders CMS to Count Mississippi Hospitals’ UCCP Days in the Medicaid Fraction of the Medicare DSH Payment Formula

In a ruling dated June 10, 2019, the United States Court of Appeals for the Fifth Circuit sided with Mississippi hospitals in a dispute over the calculation of the Medicare DSH payment. Forrest General Hospital v. Azar, No....more

7/8/2019 / Appeals , Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Hospitals , Medicaid , Medicare , Social Security Act

CMS Releases FY 2020 Medicare IPPS and LTCH PPS Proposed Rule and Proposes Key Changes to Several Regulatory Requirements

On April 23, 2019, CMS issued its annual Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System Proposed Rule for FY 2020 (the Proposed Rule), which will affect...more

4/30/2019 / Centers for Medicare & Medicaid Services (CMS) , Comment Period , Graduate Medical Education , Health Care Providers , Healthcare , Hospitals , Inpatient Prospective Payment System (IPPS) , Long Term Care Facilities , Medicare , Proposed Rules , Quality Payment Program (QPP) , Regulatory Requirements

CMS Issues Proposed Rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System

The display copy of the proposed rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) was posted on the Federal Register website last week (the Proposed Rule). The IPF PPS pays...more

4/26/2019 / Centers for Medicare & Medicaid Services (CMS) , Critical Access Hospitals , Healthcare Facilities , Hospitals , Inpatient Billing , Proposed Rules , Psychiatric Hospitals

CMS to Begin Enforcing “Longstanding” Accounting Classification Rule for Crossover Bad Debts

Last week, CMS announced on its website that for cost reporting periods beginning on or after October 1, 2019, providers must comply with a so-called “longstanding” rule to claim reimbursement for crossover bad debts from the...more

4/10/2019 / Accounting , Bad Debt , Centers for Medicare & Medicaid Services (CMS) , GAAP , Health Care Providers , MACs , Medicare , Reimbursements

Eighth Circuit Upholds CMS’s Methodology for Calculating the Volume Decrease Adjustment for Cost Reporting Periods Preceding...

Last week, the United States Court of Appeals for the Eighth Circuit issued a consolidated opinion for three cases in which it upheld the methodology that CMS used to calculate the volume decrease adjustment (VDA) for...more

3/21/2019 / Appeals , Centers for Medicare & Medicaid Services (CMS) , Hospitals , Inpatient Prospective Payment System (IPPS) , Medicare , Reimbursements

Alek Pivec

King & Spalding

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