Articles and Blogs

As of February 14, 2025, hospitals[1] will be required to provide notice to patients who are admitted as inpatients but who are later reclassified as outpatients receiving observation services (referred to as “change in patient status”). These patients who receive a change in patient status may request an expedited determination from the Centers for... READ MORE

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

Starting on August 1, 2023, Medicare validation edits will be activated to require service location addresses on the UB-04 hospital claim form to match exactly with the service location enrolled in Medicare’s Provider Enrollment, Chain, and Ownership System (“PECOS”). Background In a previous article, we reported on the Center for Medicare & Medicaid Services... READ MORE

Over the last 12 months, the Centers for Medicare & Medicaid Services (“CMS”) has received many reports of hospice fraud. In addition, CMS has seen the number of enrolled hospices increase significantly in Arizona, California, Nevada and Texas, raising concerns about market oversaturation.  On July 12, 2023, CMS released a Medicare Learning Network article (the “CMS Oversight Policy”)... READ MORE

On June 8, 2023, the Centers for Medicare & Medicaid Services (“CMS”) announced the Making Care Primary Model (“Model”), a new multi-payor, voluntary primary care model tested by the Center for Medicare and Medicaid Innovation (“CMMI”) and aimed at strengthening the primary care infrastructure for Medicare and Medicaid patients. The Model focuses on primary... READ MORE

The Centers for Medicare & Medicaid Services (“CMS”) is now accepting applications from ACOs to participate in the Medicare Shared Savings Program (“MSSP” or “Program”) for the agreement period beginning January 1, 2024. The application process is split into two phases. Phase 1 of the application submission process opened May 18, 2023, and closes... READ MORE

Could it be that CMS is implementing changes in the Medicare Communications and Marketing standards that will change the content and tone of the omnipresent television and radio advertisements targeted at potential enrollees? On the heels of publishing a final rule modifying the regulations for Medicare communications and marketing in April, on May 10,... READ MORE

March 17, 2023, was the transition period deadline for full state compliance with the Home and Community-Based Services (“HCBS”) Final Regulation.  As part of the steps to get ready for this deadline, in late 2022, the Centers for Medicare & Medicaid Services (“CMS”) visited several settings in multiple states that were identified by the... READ MORE

On February 7, 2023, the Department of Justice (“DOJ”) announced that it recovered over $2.2 billion in False Claims Act (“FCA”) related settlements and judgments in the federal fiscal year 2022. While this is less than half of the previous year’s recovery of $5.6 billion, the number of cases settled was the second highest... READ MORE

Medicare payment policy changes established under the CMS CY 2023 Medicare Physician Fee Schedule (“MPFS”) Final Rule, issued on November 1, 2022, become effective January 1, 2023. Below is a high-level summary of significant changes established for 2023. Evaluation and Management (E/M) Visits Over the past several years, CMS engaged in efforts with the... READ MORE