CMS Releases Final Medicare Outpatient Observation Notice

The Centers for Medicare & Medicaid Services (“CMS”) posted the final approved version of the Medicare Outpatient Observation Notice (“MOON”) on the CMS Beneficiary Notices Initiative website on December 8, 2016.[1]  According to CMS, all hospitals and critical access hospitals (“CAHs”) are required to provide the MOON beginning no later than March 8, 2017. Continue reading

Hot Off the Presses! CMS Issues Final Overpayment Regulations

On Friday, February 12, 2016, the Centers for Medicare and Medicaid Services (CMS) issued the final overpayment reporting and refunding rule for Medicare Parts A and B overpayments (Final Rule). This Final Rule adopts federal regulations to implement Section 6402(a) of the Affordable Care Act (ACA) enacted in March 2010 that requires the identification, reporting and refunding of certain overpayments from the Medicare and Medicaid programs (the “Overpayment Law”). CMS had previously issued a proposed rule in February 2012 containing regulations to implement the Overpayment Law, which raised several questions and compliance challenges by physicians and other health care providers. Continue reading

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:

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