Matthew Westbrook on Centers for Medicare & Medicaid Services (CMS)

CMS to Immediately Begin Auditing Medicare Advantage Plans in Significant Expansion of Enforcement Efforts

On May 21, 2025, the Centers for Medicare and Medicaid Services (“CMS”) announced a significant expansion of its auditing efforts with respect to Medicare Advantage (“MA”) plans....more

5/27/2025 / Audits , Centers for Medicare & Medicaid Services (CMS) , Enforcement Actions , Healthcare , Healthcare Fraud , Medicare Advantage , Regulatory Requirements , Reimbursements , Risk Management , Trump Administration

Disproportionate Impact: Supreme Court Narrows Disproportionate Share Hospital Reimbursement to Supplemental Security Income Cash...

The U.S. Supreme Court has issued a significant ruling affecting hospitals that serve low-income Medicare beneficiaries, narrowing the interpretation of the Disproportionate Share Hospital (“DSH”) payment formula. In...more

5/23/2025 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Government Agencies , Health Care Providers , Healthcare , Healthcare Facilities , Hospitals , Medicaid , Medicare , Reimbursements , SCOTUS , Statutory Interpretation , Supplemental Security Income (SSI)

Post‑Chevron Spotlight: Federal Court Nixes FDA Rule Reclassifying Laboratory Services as Medical Devices

In another rebuke to federal regulatory overreach, the U.S. District Court for the Eastern District of Texas (“District Court”) has vacated the Food and Drug Administration’s (“FDA”) 2024 final rule that sought to bring...more

4/16/2025 / Administrative Procedure Act , Centers for Medicare & Medicaid Services (CMS) , Chevron Deference , Clinical Laboratories , Food and Drug Administration (FDA) , Judicial Review , Laboratory Developed Tests , Loper Bright Enterprises v Raimondo , Medical Devices , Regulatory Authority , Statutory Interpretation

HHS Scraps Richardson Waiver, Clearing Way for Faster Rulemaking

On March 3, 2025, the United States Department of Health and Human Services (“HHS”) issued a policy statement rescinding the Richardson Waiver, a policy in place since 1971 that required notice-and-comment rulemaking for...more

3/13/2025 / Administrative Procedure Act , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Final Rules , Medicaid , Medicare , Regulatory Authority , Regulatory Reform , Regulatory Requirements , Rulemaking Process

CMS Publishes Final Rule, Effective January 1, 2025, Addressing the Requirements for Reporting and Returning Overpayments

The standard for an “identified overpayment” under Medicare Parts A–D now aligns with section 1128J(d)(4)(A) of the Social Security Act, which incorporates by reference the Federal False Claim Act’s (the “FCA”) “knowledge”...more

1/28/2025 / Centers for Medicare & Medicaid Services (CMS) , Compliance , Department of Justice (DOJ) , Enforcement , False Claims Act (FCA) , Final Rules , Medicare , Medicare Advantage , Overpayment , Reporting Requirements , Risk Management

CMS Proposes Additional Modifications to the Overpayment Rule Relating to the Deadline for Reporting and Returning Overpayments

In the context of Medicare Advantage (“MA”) reform initiatives, we previously addressed the Centers for Medicare & Medicaid Services’ (“CMS”) December 27, 2022 proposal to amend its regulations set forth at 42 C.F.R. §...more

8/6/2024 / Centers for Medicare & Medicaid Services (CMS) , False Claims Act (FCA) , Final Rules , Healthcare Fraud , Investigations , Medicare Advantage , Medicare Part D , Overpayment , Physician Fee Schedule , Proposed Rules , Regulatory Reform , Reporting Requirements , Voluntary Disclosure

The Supreme Court’s Ruling Narrows Available FCA Scienter Defenses

In a unanimous opinion, the United States Supreme Court (“Court”) recently held that the False Claims Act’s (“FCA”) scienter requirement refers to a defendant’s knowledge and subjective beliefs, rather than what a...more

6/20/2023 / Centers for Medicare & Medicaid Services (CMS) , False Claims Act (FCA) , Medicaid , Medicare , Misrepresentation , Safeco Insurance Co of America v Burr , Scienter , SCOTUS , Subjective Standard , Vacated

Medicare Advantage 2024 Rate Announcement – Further Impacts to Risk Adjustment

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (Rate Announcement). This Rate...more

4/4/2023 / Centers for Medicare & Medicaid Services (CMS) , False Claims Act (FCA) , Fee-for-Service , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , Medicare Part C , Medicare Part D , MedPAC , Social Security Act

President Biden Announces the End of the COVID-19 Emergencies: The Health Care Industry Has Less Than Four Months to Prepare

After multiple extensions over the past three years, on Monday, January 30, 2023, President Biden announced that the COVID-19 national emergency and public health emergency (“PHE”) will officially end on May 11, 2023....more

2/3/2023 / Biden Administration , Centers for Medicare & Medicaid Services (CMS) , Coronavirus/COVID-19 , Extensions , Health Care Providers , Healthcare , Healthcare Facilities , Public Health Emergency , Reimbursements

The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule

This past week, the Supreme Court of the United States (Supreme Court) denied UnitedHealthcare Insurance Company’s (UnitedHealthcare) petition for a writ of certiorari (Petition) challenging, in part, the Centers for Medicare...more

6/27/2022 / Centers for Medicare & Medicaid Services (CMS) , Denial of Certiorari , False Claims Act (FCA) , Fee-for-Service , Health Insurance , Healthcare , Medicare Advantage , Overpayment Recovery Time Limits , SCOTUS

Health Care Providers on Alert: Two Hospitals Penalized for Continuous Noncompliance with the Hospital Price Transparency Rule

We previously discussed the requirements of the Hospital Price Transparency Rule (“Rule”) on health care providers and health plans, as well as CMS’s proposal to increase penalties for a hospital’s failure to comply with the...more

6/20/2022 / Centers for Medicare & Medicaid Services (CMS) , Civil Monetary Penalty , Enforcement Actions , Health Care Providers , Healthcare , Hospitals , Noncompliance , Price Transparency

CMS Responds to Industry Stakeholder Feedback, Redesigns and Renames the GPDC Model for DCEs as the ACO REACH Model

On February 24, 2022, the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), announced the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH)...more

3/9/2022 / ACOs , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Fee-for-Service , Healthcare , Healthcare Reform , Medicare , REACH , Value-Based Care

CMS Corrects Inadvertent Omissions in Recent Stark Law Regulatory Amendments, Clarifies Reach of the Prohibition Related to...

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) released its final rules for the 2022 Medicare Physician Fee Schedule (PFS Final Rule) and 2022 Medicare Hospital Outpatient Prospective Payment System...more

11/17/2021 / Centers for Medicare & Medicaid Services (CMS) , Compensation Agreements , Final Rules , Health Care Providers , Healthcare , Healthcare Reform , Medicare , New Regulations , Outpatient Prospective Payment System (OPPS) , Physician Fee Schedule , Physicians , Regulatory Agenda , Rulemaking Process , Self-Referral , Stark Law

Matthew Westbrook

Proskauer Rose LLP

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