When Oklahoma Blue Cross-Blue Shield terminated Dr. Gude’s provider agreement, he decided to fight back. He sued the Blues in federal court, alleging they had violated—and this is the imaginative part—Oklahoma’s Consumer...more
Physician licensing is, and always has been, a matter for the states. But ease of travel from one state to another has long placed a strain on that approach, as physicians and patients alike move easily from one state to...more
Last Monday the Office of Inspector General (OIG) of Health & Human Services posted an advisory opinion (No. 14-07) allowing a Medigap insurance company to strike a deal with hospitals for discounts—even waivers—of the...more
8/28/2014
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Deductibles ,
Department of Health and Human Services (HHS) ,
Discounts ,
Healthcare ,
Hospitals ,
Inpatient Billing ,
Insurance Industry ,
Medicare ,
Medigap ,
OIG
Indirect graduate medical costs, or IGME, are what Medicare allows teaching hospitals in increased Medicare rates. IGME represents the indirect costs to a teaching hospital of hosting residents and interns—costs above and...more
An Institute of Medicine committee issued its long-awaited study on Graduate Medical Education (GME) funding on July 29, 2014. The committee, headed by two former Centers on Medicare & Medicaid Services administrators, Gail...more
When the government accuses a hospital of committing Medicare fraud by billing for unnecessary surgeries, the hospital has a real problem on its hands. It’s at war with the government, and that’s expensive, as well as...more
In U.S. ex rel. Corporate Compliance Assocs. v. N.Y. Society for the Relief of the Ruptured & Crippled the court ruled that the whistleblower failed to meet the False Claims Act’s requirement that allegations be described...more
Once again the Obama administration has been tripped up in launching a healthcare-related online system. This time the problem concerns the Physician Payments Sunshine Act—the act that is supposed to enable the public to see...more
Medicare’s Value-Based Purchasing (VBP) program produced no improvement in either quality of care or patient satisfaction during its first nine months of operation. That’s the finding of a study led by Andrew Ryan, of the...more
Medicare and Medicaid providers lie awake at night worrying about disgruntled—or worse yet, fired—finance officers filing whistleblower suits. After all, Medicare and Medicaid regulations are notoriously complicated, and...more
It’s been a long time since Orlando’s Halifax Hospital got any good news from the federal court hearing the whistleblower case brought by employee Elin Baklid-Kunz. Earlier this year the hospital had to agree to an $85...more
Teaching hospitals and physicians who speak at continuing medical education (CME) programs should be interested in a July 11, 2014, announcement by the Centers for Medicare & Medicaid Services (CMS). The announcement proposes...more
Earlier this week HHS came out swinging in the latest round of its battle with the Pharmaceutical Research & Manufacturers of America (PhRMA) over the Affordable Care Act’s provisions on 340B and orphan drugs. HHS reasserted...more
On Tuesday of last week the D.C. Circuit Court ruled that the Provider Review Reimbursement Board doesn’t know what’s new. It reversed the PRRB’s decision, along with the District Court’s decision that upheld it. In doing...more
Hospitals have been complaining about the two-midnight rule since it was first announced. But mounting evidence indicates that Medicare patients themselves are suffering badly from the effects of the rule....more
Criticism of the RAC (recovery audit contractor) program is becoming a national pastime. Needless to say, hospitals hated the program from the very beginning. And little wonder. The program pays private contractors a...more
It’s a question CMS has been wrestling with since the enactment of the Sunshine Act (sometimes called the Open Payments Program) as part of the Affordable Care Act. The Sunshine Act generally requires a manufacturer to...more
Both wellness visits and behavioral health visits would be added to the list of Medicare-covered telemedicine services. And it’s not just follow-up wellness visits that would be covered. Even initial visits qualify,...more
You choose your movies, restaurants and hotels based on a five-star system: one star for the worst, five for the best. Why not choose your hospital the same way? That seems to be the reasoning behind yesterday’s...more
Who says you get what you pay for? Not the Commonwealth Fund. That organization released a study yesterday ranking the U.S. both lowest in quality and highest in cost of health care, among 11 industrialized nations....more
HHS isn’t ready to throw in the towel in the fight over expansion of the 340B program under the Affordable Care Act (ACA). On Thursday HHS said in a court filing that it will appeal last month’s federal court ruling that...more
Wednesday the American Medical Association formally adopted new telemedicine standards designed to improve patient access to physicians, utilization of telemedicine and assurance of quality and safety standards in health care...more
A hospital that provided a medically necessary heart catheterization to a health plan participant is entitled to payment by the insurance company even though the hospital failed to precertify the procedure as required by the...more
Hospitals around the country expect a big influx of armed forces veterans, starting May 30 and continuing indefinitely. And many of them have mixed feelings. On the one hand, most hospitals have at least some empty beds and...more
Last month, the Centers for Medicare and Medicaid Services (CMS) amended its Conditions of Medicare & Medicaid Participation to recognize the increasing movement of hospitals into multi-hospital systems and to facilitate both...more