Articles and Blogs

CMS recently issued a final rule to require health care payers to improve communications between the payers, providers and patients and to improve the prior authorization processes (“Final Rule”). The Final Rule aims to improve electronic exchange of health care data with a particular focus on improving the prior authorization process through the implementation... READ MORE

On January 30, 2024, the Centers for Medicare and Medicaid Services (“CMS”) issued a Request For Information (“RFI”) seeking input from interested parties regarding Medicare Advantage (“MA”) data. CMS’s goals for the RFI are to enhance data capabilities “to have better insight into [MA] programs, consider areas to increase MA data transparency, and propose... READ MORE

More than one year after its effective date, the Centers for Medicare and Medicaid Services (“CMS”) has started investigating consumer complaints alleging provider violations of the No Surprises Act. The No Surprises Act generally: (1) prohibits balance billing for out-of-network emergency services, non-emergency services provided by out-of-network providers at in-network facilities and air ambulance... READ MORE

In keeping with the trends of the commercial market, on April 22, 2019, the Centers for Medicare & Medicaid Services (“CMS”) announced opportunities to participate in new direct contracting models under Medicare’s Part A and Part B fee-for-service program. CMS intends to focus these models particularly on primary care coordination for medically complex and... READ MORE

On November 8, 2018, CMS released a letter to clinicians regarding E/M documentation and coding reform. This follows the CY 2019 Medicare Physician Fee Schedule Final Rule intentions to reduce burden on clinicians in furtherance of the agency’s “Patients Over Paperwork” initiative. Effective January 1, 2019, CMS will: Simplify the documentation of history and exam... READ MORE

On July 12, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released its proposed rule for the Calendar Year (“CY”) 2019 Medicare Physician Fee Schedule (“Proposed Rule”). Among many other changes, CMS proposed numerous modifications to the required documentation for evaluation and management (“E/M”) visits in order to alleviate the administrative burden on practitioners and... READ MORE

On August 7, 2018, the Centers for Medicare & Medicaid Services (“CMS”) issued a Memorandum (“Memorandum”) announcing a policy change to allow Medicare Advantage (“MA”) plans to implement step therapy programs for physician-administered and other Part B drugs. Step therapy is a type of prior authorization for drugs in which a health plan requires... READ MORE

On July 12, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released its proposed rule for the Calendar Year (“CY”) 2019 Medicare Physician Fee Schedule (“MPFS Proposed Rule”). Among many other changes, CMS proposed to maintain payments for certain non-excepted (non-grandfathered) off-campus provider-based hospital departments (“PBDs”) at 40 percent of the Outpatient Prospective Payment System... READ MORE

Last month the Centers for Medicare & Medicaid Services (CMS) published proposed rules for reporting of overpayments. These proposed rules, if adopted and strictly interpreted, could effectively create a twenty-year statute of limitations under the False Claims Act. READ MORE