Two recent announcements from the Centers for Medicare & Medicaid Services (CMS) offer early indicators as to how the Trump administration, including CMS administrator Dr. Mehmet Oz, may approach the Medicare Advantage (MA)...more
The Department of Justice announced this week that California-based primary care provider Seoul Medical Group, Inc. (SMG), SMG’s former president and majority owner, and California-based radiology group Renaissance Imaging...more
3/31/2025
/ Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Fraud ,
Medicare Advantage ,
Medicare Fraud ,
OIG ,
Physicians ,
Settlement
On December 10, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule, which, if finalized as proposed, has potentially significant implications for Medicare Advantage (MA) plans and Medicare...more
12/16/2024
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Comment Period ,
Deadlines ,
Health Insurance ,
Healthcare ,
Marketing ,
Medicare Advantage ,
Medicare Part C ,
Medicare Part D ,
Pharmaceutical Industry ,
Prescription Drugs ,
Proposed Rules ,
Regulatory Agenda
On September 13, the U.S. Department of Health and Human Services Office of Inspector General (OIG) published Advisory Opinion 24-08, in which it declined to approve a proposal by a Medicare Advantage organization (MAO)...more
9/19/2024
/ Advisory Opinions ,
Anti-Kickback Statute ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Employer Group Health Plans ,
Health Insurance ,
Healthcare ,
Medicare ,
Medicare Advantage Organizations (MAOs) ,
OIG ,
Shared Savings Program
On April 4, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year (CY) 2025 Medicare Advantage (MA) Final Rule (Final Rule), which will have significant implications for MA plans and other industry...more
4/16/2024
/ Agents ,
Anti-Competitive ,
Beneficiaries ,
Brokers ,
Centers for Medicare & Medicaid Services (CMS) ,
Equity ,
Final Rules ,
Healthcare ,
Marketing ,
MCOs ,
Medicaid ,
Medicare Advantage ,
Medicare Part D ,
Mental Health ,
Shareholders ,
Third-Party Service Provider
On November 15, CMS published a proposed rule, which, as currently written, has potentially significant implications for Medicare Advantage (MA) plans and Medicare Prescription Drug Benefit Program (PDP) plans in Contract...more
11/16/2023
/ Brokers ,
Centers for Medicare & Medicaid Services (CMS) ,
Compensation ,
Health Care Providers ,
MCOs ,
Medicare Advantage ,
Mental Health ,
Opioid ,
Proposed Rules ,
Quotas ,
Risk Assessment ,
Telehealth
As addressed in the first installment of this three-part series, healthcare providers face potential audits from an increasing number of Medicare and Medicaid contractors. Failing to respond properly can lead to significant...more
On February 1, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Program Final Rule (Final Rule), which will take effect on April 3, 2023. The...more
On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024....more
12/21/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Department of Health and Human Services (HHS) ,
Equity ,
Health Care Providers ,
Marketing ,
Medicare ,
Medicare Advantage ,
Medicare Part A ,
Medicare Part B ,
Medicare Part C ,
Medicare Part D ,
Notice Requirements ,
Overpayment ,
Proposed Rules ,
Star Ratings ,
Termination Clauses ,
Translations ,
Utilization Review
The Centers for Medicare & Medicaid Services (CMS) recently issued Advisory Opinion No. CMS-AO-2021-01, clarifying that physician groups that furnish designated health services (e.g., laboratory, imaging) through wholly-owned...more
The COVID-19 pandemic has stressed the M&A market at every stage of the deal-making process – from complicating on-site visits and intensifying the diligence process to introducing valuation gaps (relative to pre-COVID-19...more
12/7/2020
/ Accelerated Payments ,
Buyers ,
CARES Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Coronavirus/COVID-19 ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
Economic Injury Disaster Loans ,
Employee Retention ,
False Claims Act (FCA) ,
Families First Coronavirus Response Act (FFCRA) ,
Government Investigations ,
Indemnification ,
Loan Forgiveness ,
Main Street Lending Programs ,
Material Adverse Effects ,
Paycheck Protection Program (PPP) ,
Payroll Taxes ,
Private Equity ,
Provider Relief Fund ,
Representations and Warranties ,
SBA ,
Securities and Exchange Commission (SEC) ,
Sellers ,
SIGPR ,
Tax Credits ,
Tax Deferral
Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the federal government is delivering a significant influx of money to the healthcare industry, particularly healthcare organizations, to aid in the...more
Despite the mounting pressures on healthcare entities related to the COVID-19 (coronavirus) pandemic and recent announcements of regulatory waivers and flexibility in particular areas, regulators are still showing interest in...more
Recent opinions by the Fifth Circuit, the Northern and Southern Districts of Texas, and the District of South Carolina offer hope to providers seeking relief from substantial monetary recoupments during the Medicare appeals...more
9/28/2018
/ Administrative Appeals ,
Administrative Law Judge (ALJ) ,
Administrative Remedies ,
Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Complaint Procedures ,
Health Care Providers ,
Injunctive Relief ,
Irreparable Harm ,
Medicare ,
Medicare Claims Appeals Process ,
Motion for Reconsideration ,
OMHA ,
Overpayment ,
Physician Medicare Reimbursements ,
Recoupment ,
Redeterminations ,
TRO
August 24, 2018 marked a busy day for the U.S. Department of Health & Human Services' (HHS) self-designated "Regulatory Sprint to Coordinated Care," an initiative aimed at dismantling the regulatory barriers to providers...more
9/7/2018
/ Alternative Payment Models (APM) ,
Anti-Kickback Statute ,
Centers for Medicare & Medicaid Services (CMS) ,
Civil Monetary Penalty ,
CMMI ,
Comment Period ,
Commercial Reasonableness ,
Cost-Sharing ,
Cybersecurity ,
Data-Sharing ,
Department of Health and Human Services (HHS) ,
EHR ,
Fraud and Abuse ,
Health Care Providers ,
Hospitals ,
Incentives ,
Medicare Shared Savings Program ,
OIG ,
Physicians ,
Public Comment ,
Request For Information ,
Safe Harbors ,
Stark Law ,
Telehealth ,
Value-Based Care ,
Waivers
On July 17, 2018, the U.S. House of Representatives' Ways and Means Committee Subcommittee on Health ("Subcommittee") expressed its commitment to modernizing the Stark Law during a hearing in which industry and government...more
7/19/2018
/ ACOs ,
Affordable Care Act ,
Alternative Payment Models (APM) ,
Anti-Kickback Statute ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Health Care Providers ,
Hospitals ,
Medicare Access and CHIP Reauthorization (MACRA) ,
OIG ,
Request For Information ,
Stark Law ,
Ways and Means Committee
In January 2018, Centers for Medicare & Medicaid Services (CMS) announced additional information regarding a new Low Volume Appeals (LVA) settlement option and an expanded Settlement Conference Facilitation (SCF) as part of...more
4/13/2018
/ Administrative Law Judge (ALJ) ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Low Volume Appeals Settlement Options (LVA) ,
MACs ,
Medicare ,
Medicare Appeals Council ,
Medicare Claims Appeals Process ,
Medicare Part A ,
Medicare Part B ,
OMHA