HHS’ Office of Inspector General Releases New Report

The HHS’ Office of Inspector General released a report this past Monday indicating that a number of states providing services to Medicaid beneficiaries enrolled in managed care are not complying with the mandatory quarterly reporting requirements.  In response to this study, the OIG recommended that the Center for Medicare and Medicaid Services use its authority to begin withholding federal funds from non-compliant states citing that the data is crucial to Medicaid oversight and the prevention of fraud and abuse.  Although states struggle with capturing the level of quality data needed to complete the reporting requirements, CMS continues to make enforcement a priority.  In response to the report, CMS indicated that it has already issued a notice of proposed rulemaking that would allow for the withholding of federal funds.  For those states who lack the ability to capture the data whether through lack of technological infrastructure or other reasons, this latest policy does not bode well.  For more information, go to: http://www.modernhealthcare.com/article/20150706/NEWS/150709966/not-all-states-reporting-required-medicaid-data-oig-says.

Written by: Traci S. Thompson


$1,000,000 Fine Imposed for Incorrect In-network Information

In a letter from the Centers for Medicare & Medicaid Services (“CMS”) Medicare Parts C and D Oversight and Enforcement Group issued on April 2, 2015, CMS imposed a civil money penalty of $1,000,000 on health insurer, Aetna, Inc. The $1,000,000 fine was based on Aetna’s “failure to disseminate clear and accurate information regarding the number, mix, and distribution (addresses) of network pharmacies from which enrollees may obtain covered Part D drugs,” which CMS found violated obligations imposed by  42 C.F.R. § 423.128(a)(2) and 42 C.F.R. § 423.509(a)(2). Continue reading

New York Whistleblower Court First to Address What It Means to “Identify” Overpayment under ACA’s 60 Day Rule

For the first time since its enactment as part of the Affordable Care Act (ACA) in 2010, a federal court in a whistleblower action will consider a provision requiring providers to return overpayments within sixty days of when they are “identified.”  The upcoming decision by the United States District Court for the Southern District of New York in U.S. ex rel. Kane v. HealthFirst Inc. et al  will likely be just  the first of many decisions on the subject.   Providers and government regulators are poised for what could prove a lengthy dispute at both the trial and appellate levels around the ACA’s 60 day rule and its interplay with overpayments in the False Claims Act (FCA) context. Continue reading

CMS Issues Proposed ACO Rule to Address Industry Concerns and Encourage Participation in Alternative Risk-Based ACO Models

On Monday, December 1, 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued a Proposed Rule with several proposed changes to the regulations finalized in 2011 for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP).  According to CMS, the Proposed Rule is intended to reduce administrative burdens and improve program function and transparency for ACOs participating in the MSSP. There are currently 330 ACOs serving almost 5 million Medicare beneficiaries in 47 states. Continue reading

The New Two-Midnight Rule – Scrutiny Delayed until March 31, 2014

CMS indicated on its website in early November that it is extending the implementation period for another three months, until March 31, 2014. The website says that, “in general, CMS will not conduct post-payment patient status reviews for claims with dates of admission of October 1, 2013 thru March 31, 2014.” CMS also issued two new guidance documents on its website that describe selecting and reviewing hospital claims for patient status.

Written by: Emily Grey

Grey, Emily headshot