Matthew Westbrook on Medicare

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)

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

First Circuit Clarifies FCA Liability Standard for AKS Violations, Deepening Circuit Split

The First Circuit has issued its long-anticipated opinion in United States v. Regeneron Pharmaceuticals, Inc., clarifying the standard for establishing False Claims Act (“FCA”) liability based on Anti-Kickback Statute (“AKS”)...more

2/26/2025 / Anti-Kickback Statute , Appeals , Causation , Corporate Counsel , Department of Justice (DOJ) , False Claims Act (FCA) , Fraud , Medicare , Pharmaceutical Industry

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

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

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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