Medicare Payment and Reimbursement

A proposed Medicare condition of participation would bring a slew of new requirements for OB care

Note: HFMA’s coverage of the payment update in the outpatient payment proposed rule can be found here. Hospitals intending to participate in Medicare must meet new standards for obstetric (OB) care, according to CMS’s proposed outpatient rule for 2025. The rule proposes to establish a new Medicare condition of participation (CoP), whereby hospitals and critical…

Nick Hut July 12, 2024

Medicare’s proposed outpatient payment update for 2025 doesn’t keep pace with hospital costs, advocates say

Note: Additional coverage of the proposed rule can be found here. Hospital advocates expressed dissatisfaction with the payment update in Medicare’s 2025 proposed rule for hospital outpatient care and ambulatory surgical centers (ASCs). CMS proposes to increase the Medicare rate for outpatient services and ASCs by 2.6%, resulting from a 3% jump in the market…

Nick Hut July 11, 2024

CMS proposes to hold Medicare ACOs harmless for spending levels stemming from catheter-billing fraud

CMS has issued a proposed rule to mitigate the impact of a high-profile Medicare fraud scheme on accountable care organizations (ACOs). The rule seeks to address “significant, anomalous and highly suspect billing activity for selected intermittent urinary catheters on Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) claims” as applied to ACOs in the…

Nick Hut July 9, 2024

Healthcare providers face Medicare payment-rate penalties for information blocking under new rule

Healthcare providers will receive a lower Medicare payment update if they are deemed to have engaged in information blocking, according to a final rule from HHS and CMS. For hospitals, a violation will leave the organization noncompliant with the Promoting Interoperability Program, meaning it would lose out on three-quarters of the annual market-basket update for…

Nick Hut July 3, 2024

Supreme Court ruling on Chevron makes regulations in healthcare (and other industries) more vulnerable to legal challenges

The U.S. Supreme Court issued a decision Friday that has dramatic implications for the regulatory infrastructure in healthcare, among many other industries. Since it was established in a 1984 case, Chevron deference has served as guidance to courts that regulatory authorities such as CMS and dozens of others across the federal government have license to…

Nick Hut June 28, 2024

CMS’s 2024 MA rule brings some improvements but falls short of addressing all providers’ concerns

Hospitals and other healthcare providers welcomed CMS’s release in 2023 of the 2024 Medicare Advantage and Part D final rule (CMS-4201-F).a The rule represents CMS’s effort to refine the practices of MA organizations by placing limitations on prior authorization, elevating requirements for provider directories and making comprehensive adjustments to the MA and Part D quality…

Mattie Smith, JD June 19, 2024

Hospitals can bring their case on disproportionate share hospital payments to the Supreme Court

The Supreme Court granted hospitals’ request that it hear their appeal about the formula for determining Medicare disproportionate share hospital (DSH) payments, landing the case on the docket for the 2024-25 term. More than 200 hospitals are plaintiffs in the case. A federal district court ruled for HHS and against the hospitals in 2022, and…

Nick Hut June 12, 2024

Health system CEO tells Congress proposed 340B changes would be harmful to organizations like his

A health system executive visited Capitol Hill recently to provide the hospital perspective on the 340B Drug Pricing Program — a viewpoint that increasingly is coming under fire among policymakers. Matthew Perry, president and CEO of Genesis HealthCare System in Zanesville, Ohio, appeared at a House subcommittee hearing June 4 to give insight on why…

Nick Hut June 10, 2024

For providers, application of the 2-midnight rule to Medicare Advantage appears to bring a revenue influx

Hospitals appear to have gained a significant, albeit likely short-term, revenue boost from CMS’s 2023 directive to Medicare Advantage (MA) health plans regarding the two-midnight rule. The rule first was instituted in 2013 for Medicare fee-for-service (FFS), requiring the program to cover hospital stays as inpatient admissions if the admitting physician expects the stay to…

Nick Hut June 3, 2024

340B providers are at a disadvantage after the latest court ruling on contract pharmacies

A decision issued by an appeals court represents the latest setback for 340B providers hoping to secure widespread access to price discounts on Medicare Part B drugs. The U.S. Court of Appeals for the District of Columbia Circuit on May 21 upheld a district-court ruling that drug manufacturers can impose restrictions on the 340B discounts…

Nick Hut May 24, 2024
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