CMS Issues 2015 Managed Care Rate Setting Consultation Guide

On Wednesday, October 2, the Centers for Medicare and Medicaid Services (“CMS”) issued its  2015 consultation guide for states to use when setting reimbursement rates with respect to any Medicaid managed care program subject to actuarial soundness requirements in 42 CFR 438.6 during rating periods starting January 1, 2015.  The guide “describes information that CMS expects states to provide […]

National Health Care Fraud Abuse Control Program Reports Record Recoveries and Return on Investment

Through their Health Care Fraud Abuse Control program (“HCFAC”), the United States Departments of Justice (“DOJ”) and the United States Department of Health and Human Services (“HHS”) have recovered more than $19 billion from health care providers over the last five years.  A report released on February 26 shows that the program’s three-year return on […]

New York and CMS Announce Partnership to Coordinate Care for Medicare-Medicaid Dual Enrollees

Today, CMS issued a Press Release announcing that it is conducting a demonstration project with New York State known as the Fully Integrated Duals Advantage (FIDA) demonstration.  Under this capitated demonstration, approximately 170,000 New Yorkers who are people eligible for Medicaid and Medicare in NYC, Long Island and Westchester County will be able to join […]

Medicaid Director Announces House Oversight Committee Interest in Managed Long Term Care

On June 20, 2013, at the Managed Care Policy Meeting, Jason Helgerson announced that the House Oversight Committee has asked CMS to investigate managed long term care plans related to the use and possible abuse of social day care programs in New York City.  Mr. Helgerson reminded Plans that enrollment from Social Day Care Programs […]

CMS Issues Section 1135 Waivers for New York and New Jersey

The Centers for Medicare and Medicaid Services (CMS) approved waivers for New York and New Jersey under Section 1135 of the Social Security Act.  The waivers ease certain legal requirements on healthcare providers who are serving those impacted by Sandy.  The Section 1135 waiver for New York is available here.  The waivers relax the rules […]

False Claims Act: Payment vs. Participation Regulations

In U.S. ex rel. Williams v. Renal Care Group, Inc. (Case No. 11-5779) (October 5, 2012), the Sixth Circuit Court of Appeals reversed a grant of summary judgment in favor of the United States on two main False Claims Act (FCA) claims relating to Medicare reimbursement of dialysis supplies. In doing so, the Court issued […]

New York State Allegedly Overbilled $15 Billion for State-Operated Facilities for Developmentally Disabled

On May 17, 2012, the U.S. Department of Health and Human Services, Office of Inspector General (OIG) released a report that found Medicaid overpayments to New York State-operated developmental centers. The OIG concluded that, in 2009, State-operated  facilities for the developmentally disabled received $1.7 billion in Medicaid payments in excess of the reported costs of these facilities. […]

HIPAA: Conversion to Version 5010

As of January 1, 2012, all healthcare providers were required to transition from version 4010/4010A to version 5010 standards for submitting electronic transactions, and the failure to comply may result in claim denials or a government investigation. CMS has repeatedly postponed enforcement, but it appears the agency will begin to enforce civil monetary penalties against […]

OIG Releases Report on Medicaid Rates for New York State-Operated Developmental Centers

The Office of Inspector General (“OIG”) released a report yesterday based on its review of the reimbursement rates for New York State-operated developmental centers.   The report found that the Medicaid daily rate for state-operated developmental centers was inflated, and that New York State (State) received $700 million more in federal funding in fiscal year 2009 […]

HHS Selects 32 Organizations for the Pioneer ACO Model

The U.S. Department of Health and Human Services (HHS) recently selected 32 Accountable Care Organizations (ACOs) to participate in the Pioneer ACO Model designed by the CMS Innovative Center to test the impact of several innovative payment arrangements to support these organizations in achieving the goals of better care and outcomes at a lower cost.