Latest Articles

In a rare display of unity, President Donald Trump and bipartisan Congressional leaders have highlighted their shared commitment to tackling “surprise” medical billing – when an insured patient is subject to unexpectedly high out-of-pocket costs for out-of-network care that is beyond their control.  Such surprise billing can occur when a patient receives emergency care from an out-of-network provider but they could not choose their provider, or when a patient is treated at an in-network hospital…
The Centers for Medicare & Medicaid Services (CMS) has issued a final rule streamlining the process for Medicare Parts A and B claims appeals and for Medicare Part D coverage determination appeals in order to “reduce associated burden on providers, beneficiaries, and appeals adjudicators.”  In particular, the final rule: Removes the requirement in Medicare Parts A and B claim and Part D coverage determination appeals that appellants sign appeal requests (CMS estimates that 284,486 appeal…
The Centers for Medicare & Medicaid Services (CMS) is revoking the authority of states to “divert” certain Medicaid provider payments to a third party (rather than make the payment directly to the provider) to fund other costs on behalf of the provider “for benefits  such as health insurance, skills training, and other benefits customary for employees.”  This reassignment authority, which was granted in a 2014 rule, had been intended to “enhance state options to…
Medical equipment suppliers can submit bids for Round 2021 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) from July 16 through September 18, 2019, the Centers for Medicare & Medicaid Services (CMS) has just announced. As previously reported, Round 2021 of the CBP round will cover 16 product categories in 130 competitive bidding areas (CBAs), with contracts running from January 1, 2021 through December 31, 2023.…
Agency Promises More Frequent Drug/Device HCPCS Code Update Opportunities, Bars MACs from Adopting New Blanket Noncoverage Policies without Evidence Review   On May 2, 2019, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma outlined new improvements to the HCPCS coding and local coverage decision processes that are intended to “ensure safe and effective treatments are readily accessible to beneficiaries without delaying patient care.” First, CMS plans to move away from its single annual
The Centers for Medicare & Medicaid Services (CMS) has released its proposed rule to update the Medicare acute inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) prospective payment system (PPS) for fiscal year (FY) 2020.  Notably, the proposed rule includes a number of provisions that aim to “unleash medical innovation” by expediting access to novel medical technology – and the agency signals that similar reforms are contemplated for the hospital outpatient…
Representatives Jackie Speier (D-California) and Dina Titus (D-Nevada) have introduced HR 2143, the Promoting Integrity in Medicare Act of 2019 (PIMA), which – if enacted – would narrow the “Stark” law’s exceptions and have a direct impact on the services provided by physicians who self-refer for the performance of certain designated health services. The 2019 bill is similar to previous proposals introduced by Representative Speier in prior years. PIMA would strengthen the Stark law by…
The Centers for Medicare & Medicaid Services (CMS) has proposed a 2.7% increase in Medicare hospice payment rates for fiscal year (FY) 2020, which the agency estimates would result in a $540 million increase in Medicare payments to hospices compared with 2019 levels.  The annual update would be reduced by 2 percentage points for hospices that fail to report required quality data.  The proposed FY 2020 hospice cap is $29,993.99, compared with the FY 2019…
The Centers for Medicare & Medicaid Services (CMS) is expanding the types of durable medical equipment (DME), prosthetic, orthotics, supplies (DMEPOS) that are subject to Medicare prior authorization requirements on the basis of being “frequently subject to unnecessary utilization.”  Specifically, CMS announced that it is adding to the Required Prior Authorization List: Seven power wheelchair codes (K0857, K0858, K0859, K0860, K0862. K0863, and K0864), effective July 22, 2019. Five support surface codes (E0193, E0277, E0371.…
The Centers for Medicare & Medicaid Services (CMS) has released its proposed rule to update the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) for fiscal year (FY) 2020.  CMS projects that IRF PPS payments would rise by $195 million under the proposed rule.  Specifically, CMS proposes a 2.5% increase factor, based on an IRF market basket update of 3.0% reduced by a 0.5 percentage point multifactor productivity adjustment.  CMS proposes to rebase and…