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Showing 21 posts in Medicare.

On Friday, April 5, 2019, the Centers for Medicare & Medicaid Services (“CMS”) finalized its fall 2018 proposal to expand coverage of telehealth benefits for Medicare Advantage beneficiaries, creating a new category of benefits entitled “additional telehealth benefits.” This brief alert highlights what this development means for healthcare providers, before reviewing the various ways in which Congress and CMS have expanded the telehealth benefits available to Medicare beneficiaries throughout 2018 and 2019.

Background: Telehealth Coverage by Medicare and Medicare Advantage

Medicare Coverage of Telehealth. Historically, Medicare has only covered telehealth services delivered to Medicare fee-for-service (“FFS”) beneficiaries when the services at issue satisfy the requirements for “Medicare telehealth services” set forth in § 1834(m) of the Social Security Act, and codified at 42 U.S.C. § 1395m(m). In order to be eligible for payment, such services must satisfy five requirements: the services must be rendered to a patient in a rural health professional shortage area (“HPSA”) or in a county which is not included in a metropolitan statistical area (“MSA”) (unless an exception applies); the patient must be located at an approved “originating site;” the services must be delivered through an approved telecommunications system; the service must be rendered by an approved type of provider; and the service provided must be included on CMS’ list of approved “Medicare telehealth services,” which it updates annually. In the past few years, Congress and CMS have broadened the authority to offer telehealth based services both in Medicare FFS and in Medicare Advantage. Read More ›

Recently, many of our clients have found that more and more of their in-network, contracted claims which they have billed to the various payors are being denied, in whole or in part, for an alleged lack of medical necessity. This article provides some considerations to be made when dealing with payors who have denied claims based on medical necessity grounds.

Examine Your Contract

                Definition of Medical Necessity

Providers should examine their contracts with the payor at issue. First, determine how the terms “Medical Necessity” or “Medically Necessary Services” (or the equivalent) have been defined in your contract. Ensuring that the services in question comply with that definition will be critical to succeeding in any challenge to the payor’s denial of the claim. Should any challenge of the payor’s denial result in litigation or arbitration, your expert witness will also need to become very familiar with the definition included in your contract and be able to support that the services provided do meet the definition provided. Read More ›

On Friday, December 21, 2018, CMS issued a final rule, referred to as “Pathways for Success,” that makes significant changes the Medicare Shared Savings Program. Issued just before the holidays, various stakeholders will likely have varying opinions about whether this final rule constituted an early gift or lump of coal. Among other things, the final rule overhauls the current track system for participating accountable care organizations, or ACOs, and requires a more rapid transition to assumption of downside risk. The two new tracks available to participating ACOs will go into effect for agreement periods commencing on or after July 1, 2019. Read More ›

On April 24, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its Hospital Inpatient Prospective Payment Systems (IPPS) proposed rule for Fiscal Year 2019 (Proposed Rule).  Contained within the Proposed Rule was a notice from CMS of the closure of two teaching hospitals and the opportunity for hospitals to apply for the newly available graduate medical education resident slots under Section 5506 of the Affordable Care Act (ACA).  Read More ›

CMS Proposes Changes to Telehealth Reimbursement, Stark, Substance Use Disorder Treatment Reimbursement, and Evaluation & Management Reimbursement in the  CY 2019 Physician Fee Schedule Proposed Rule

On Thursday, July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 Physician Fee Schedule (PFS) Proposed Rule (the Proposed Rule). Read More ›

For media assistance, please contact Maura Fisher at 202-580-7714.