Medicare and Regulations - Health Care Quality Digest

CMS, HHS can use existing federal authority to regulate AI safety in hospitals: JAMA

Fierce Healthcare

JULY 30, 2024

As artificial intelligence rapidly makes inroads in healthcare, federal agencies already have the authority to regulator AI at the hospital bedside, according to some healthcare researche | An article published in JAMA Health Forum argues that through the conditions of participation in Medicare and Medicaid, CMS has the authority to oversee how hospitals (..)

Regulations

Regulations Hospitals Medicaid Medicare

Remote patient monitoring in Medicare needs more oversight: OIG

Health Care Dive

SEPTEMBER 25, 2024

Regulators say Medicare needs more data and oversight to avoid fraud and misuse. Digital health advocates argue the service is still crucial for managing chronic conditions.

Medicare

Medicare Regulations

Medicare Advantage risk assessments driving billions in costs each year

Fierce Healthcare

MAY 9, 2024

Medicare Advantage plans have come under fire for upcoding that can increase the payouts they receive, and regulators point to health risk assessments as a likely culprit in this increase in coding | Medicare Advantage plans have come under fire for upcoding that can increase the payouts they receive, and regulators point to health risk assessments (..)

Medicare

Medicare Regulations

AHIP 2024: Cutting through the 'nostalgia' for traditional Medicare

Fierce Healthcare

JUNE 17, 2024

LAS VEGAS—The eyes of many regulators and lawmakers are on Medicare Advantage (MA), and, amid rising criticism of the program, one industry leader is making the case that "nostalgia" for traditiona | LAS VEGAS—The eyes of many regulators and lawmakers are on Medicare Advantage, and amid rising criticism of the program, one industry leader (..)

Medicare

Medicare Regulations

CMS to get ‘tougher’ on Medicare Advantage, official promises

Health Care Dive

SEPTEMBER 22, 2023

CMS Deputy Administrator Jon Blum signaled regulators could increasingly crack down on bad actors in the MA program, which now covers more than half of Medicare seniors.

Medicare

Medicare Regulations

CMS to lower importance of ‘call center’ metric in Medicare Advantage star ratings

Health Care Dive

NOVEMBER 14, 2024

Regulators’ assessment of customer support centers has spurred recent lawsuits from UnitedHealthcare, Centene and Humana. But the metric “is going to have a smaller weighting on star ratings moving forward,” the director of Medicare said.

Medicare

Medicare Regulations

OIG report suggests telehealth fraud rare in Medicare

Health Care Dive

SEPTEMBER 9, 2022

A small proportion of providers that billed for telehealth — 1,714 out of 742,000 — posed a high risk of fraud or abuse to Medicare in COVID-19’s first year, regulators found.

Medicare

Medicare Regulations

CMS finalizes 2024 Medicare hospital, doctor payments, 340B fix and price transparency requirements

Health Care Dive

NOVEMBER 3, 2023

Regulators finalized a number of rules Thursday with sweeping implications for providers in the Medicare program, including rates for next year that doctors and hospitals slammed as insufficient.

Doctors

Doctors Medicare Hospitals Regulations

Medicare Advantage lobby rebuts senator’s inquiry into ‘potentially deceptive’ marketing tactics

Health Care Dive

AUGUST 24, 2022

The Better Medicare Alliance is arguing that marketing materials for MA plans are already subject to “careful regulation” and adhere to a 53-page set of federal guidelines.

Medicare

Medicare Regulations

Elevance sues HHS over Medicare Advantage star ratings

Health Care Dive

JANUARY 8, 2024

The payer is taking issue with how regulators calculated quality scores for 2024, after seeing a stars decline that could cause its bonus revenue to fall by $500 million.

Medicare

Medicare Regulations

SCOTUS rejects UnitedHealth appeal of Medicare Advantage overpayment rule

Health Care Dive

JUNE 22, 2022

The justices declined to take up the case, leaving intact a lower court ruling that backed the 2014 CMS regulation requiring swift return of overpayments.

Medicare

Medicare Regulations

Lobby-funded study argues Medicare Advantage rate cuts are worse than CMS expects

Health Care Dive

FEBRUARY 27, 2024

Medicare Advantage payment per month, per beneficiary could drop by 1% next year if regulators finalize rates as proposed, according to the analysis backed by the Better Medicare Alliance.

Medicare

Medicare Regulations

Centene sues HHS over Medicare Advantage star ratings fall

Health Care Dive

OCTOBER 23, 2024

Centene is emulating other insurers unhappy with how regulators handled quality ratings for 2025. The flurry of complaints is “symptomatic of what appear to be systemic issues” with CMS calculations, Centene said.

Medicare

Medicare Regulations

Private equity deals in MA are declining, but experts say regulators should keep an eye on this space

Fierce Healthcare

FEBRUARY 13, 2024

Private equity firms have seen plenty of potential in the rapidly growing Medicare Advantage space, but deal volumes are slowing, according to a new report. Private equity firms have seen plenty of potential in the rapidly growing Medicare Advantage space, but deal volumes are slowing, according to a new report.

Regulations

Regulations Medicare

CMS recalculates Medicare Advantage star ratings in major win for insurers

Health Care Dive

JUNE 14, 2024

The redo comes after regulators lost two court cases over the methodology used to determine 2024’s quality ratings, and should result in hundreds of millions of dollars in additional bonuses to plans that see their ratings improve.

Medicare

Medicare Regulations

HHS OIG backs nixing capital cost exemption for new hospitals

Health Care Dive

AUGUST 17, 2021

An HHS watchdog says Medicare could see significant cost savings if regulators did away with the carveout. Currently, new facilities help pay for their capital costs through a special exemption.

Hospitals

Hospitals Regulations Medicare

Medicare Advantage plans could see rates dip slightly in 2025

Health Care Dive

FEBRUARY 1, 2024

However, analysts said regulators will likely improve the payment rate in the final notice. The CMS proposed a 0.2% dip in MA rates.

Medicare

Medicare Regulations

CMS ordered to recalculate UnitedHealthcare’s 2025 MA stars

Health Care Dive

NOVEMBER 25, 2024

A Texas federal judge has sided with UnitedHealthcare in determining regulators messed up calculating its Medicare Advantage quality scores for next year. The decision could have big implications for similar pending cases.

Regulations

Regulations Medicare

CMS sets Medicaid payments to home care workers at 80%

Fierce Healthcare

APRIL 22, 2024

The Centers for Medicare & Medicaid Services is hoping to improve Medicaid enrollees’ access to care through a final rule that better compensates caregiving roles. | CMS released a series of final rules Monday, including Medicaid access regulations that some groups worry will cause providers to close.

Medicaid

Medicaid Home Care Regulations Medicare

Low-income seniors more likely to report fraudulent marketing from private Medicare plans, survey finds

Health Care Dive

SEPTEMBER 12, 2023

The survey from the Commonwealth Fund comes after regulators finalizing a rule this spring that aims to cut back on deceptive or misleading advertising for MA plans after beneficiary complaints more than doubled between 2020 and 2021.

Medicare

Medicare Regulations

Elevance Health sues HHS over Medicare Advantage star ratings

Health Care Dive

NOVEMBER 4, 2024

The payer joins several other insurers suing federal regulators over the 2025 quality ratings, which Elevance argues will cost it at least $375 million in bonus payments and rebates.

Medicare

Medicare Regulations

Private equity deals in Medicare Advantage decline, report finds

Health Care Dive

FEBRUARY 14, 2024

High interest rates and new regulations could be driving the slowdown, according to a report by the Private Equity Stakeholder Project.

Medicare

Medicare Regulations

Congress reaches spending deal with doc pay bump, delayed DSH cuts and more

Fierce Healthcare

MARCH 4, 2024

A bipartisan spending bill unveiled Sunday narrows some of this year’s cuts to physician Medicare pay, pushes back scheduled disproportionate share hospital (DSH) payment cuts and increases annual | A 1,050-page bill unveiled Sunday included several key lobbying focuses for providers but excludes other hot-button topics like potential pharmacy benefit (..)

Regulations

Regulations Medicare Hospitals

CMS proposes 2.9% cut to physician pay for 2025

Health Care Dive

JULY 11, 2024

Regulators said Medicare’s budget neutrality requirement is to blame for the reduction, which was quickly decried by provider groups. However, it’s likely Congress will step in to mitigate the drop.

Regulations

Regulations Medicare

CMS to crack down on Medicare Advantage audits, poised to claw back billions of dollars from insurers

Health Care Dive

JANUARY 30, 2023

Federal regulators have raised concerns about alleged payment abuses in the MA program for years, specifically for those tied to risk adjustments.

Medicare

Medicare Regulations

J.D. Power: MA plans beat commercial coverage on consumer satisfaction

Fierce Healthcare

AUGUST 20, 2024

Amid significant scrutiny from lawmakers and regulators on Medicare Advantage, a new report suggests that consumer satisfaction with these plans is notably higher than with commercial insurance.

Regulations

Regulations Medicare

CMS exploring models centered on social health factors

Health Care Dive

JUNE 9, 2023

Regulators said they're trying to work around restrictions regarding what groups Medicare is allowed to pay as they look to address social determinants of health.

Regulations

Regulations Medicare

Amedisys’ Medicare Advantage Gains Outpace Traditional Medicare Losses

Home Health Care

NOVEMBER 7, 2024

Non-Medicare and high-acuity care revenue continue to grow substantially at Amedisys Inc. Traditional Medicare revenue declined by close to $6 million year over year, while non-Medicare revenue increased by over $26 million. Nasdaq: AMED). While the company waits to become a part of UnitedHealth Group (NYSE: UNH) – in a $3.3

Medicare

Medicare Regulations

What Home Health Providers Need To Know About CMS’ Medicare Enrollment Changes

Home Health Care

JANUARY 31, 2024

The Medicare enrollment process undergoes annual changes at the Centers for Medicare & Medicaid Services (CMS) to ensure it remains up to date with evolving regulations, policies and health care practices. CMS recognizes that there are legitimate providers that do not bill Medicare even though they are enrolled,” Carr said.

Medicare

Medicare Regulations Medicaid Home Care

CMS tweaks ACO REACH to stabilize model

Health Care Dive

AUGUST 15, 2023

Regulators lowered enrollment minimums for accountable care organizations in the program, which allows providers to form groups to manage care and costs for fee-for-service Medicare enrollees.

Accountable Care

Accountable Care Regulations Accountability Medicare

Reimbursement Insights: Medicare and Medicaid Coverage for Cardiology Billing

p3care

SEPTEMBER 26, 2023

Medicare and Medicaid are the two biggest healthcare insurance programs in the United States. The federal government has made different rules and regulations applicable to eligible populations. Therefore, receiving reimbursement for Medicare and Medicare cardiology billing seems difficult.

Medicaid

Medicaid Medicare Regulations Prevention

Putting 2024’s Split/Shared Services Billing Regulations into Practice

HIT Consultant

APRIL 19, 2024

Medicare providers in hospitals and skilled nursing facilities (SNFs) are adjusting to new split/shared services documentation and billing regulations rolled out by the Centers for Medicare and Medicaid Services (CMS) as part of the 2024 Medicare Physician Fee Schedule (MPFS) final rule.

Regulations

Regulations Nursing Medicare Medicaid

New Medicare Marketing Definition

Triage Health Law

JULY 27, 2023

On May 10, 2023, the Center for Medicare & Medicare Services (“CMS”) issued guidance to clarify the definition of “marketing” for Medicare Advantage Plans (“MA Plans”) and Prescription Drug Plans (“PDPs”). [1] What led to the Change in Definition?

Medicare

Medicare Regulations Medicaid Prevention

EHNAC and CARIN Alliance launch new accreditation program

Healthcare It News

OCTOBER 4, 2022

The Electronic Healthcare Network Accreditation Commission and The CARIN Alliance have partnered to bring both the CARIN Code of Conduct and EHNAC’s criteria review process to health plans, health systems, EHR vendors and others for reporting to the Centers for Medicare & Medicaid Services on their data practices and privacy protections.

Regulations

Regulations Medicaid Medicare Healthcare

Regulation as a Catalyst for Innovation: Leveraging the Interoperability and Prior Authorization Mandate

Fierce Healthcare

APRIL 23, 2024

Interoperability mandates from the Centers for Medicare and Medicaid Services (CMS) have required major investments by health plans in recent years and will continue to be critical in informing ove | Facing new CMS mandates, MVP Health Care Chief Strategy Officer offers considerations to align your compliance strategy with innovation goals.

Regulations

Regulations Medicaid Medicare

Final Medicare Overpayment Rules a Mixed Bag for Providers

HKLaw

NOVEMBER 11, 2024

The Centers for Medicare & Medicaid Services (CMS) released highly anticipated updates this month to the Medicare regulations interpreting the federal 60-day overpayment refund requirement (the Overpayment Statute).

Medicare

Medicare Regulations Medicaid

Primary care practices identify needed improvements for telemedicine

Healthcare It News

MAY 31, 2023

They also said clinicians reported needing more formal training on how to communicate more effectively over a virtual platform and about state regulation. Regulations that varied widely also affected their use of telehealth platforms. But the telehealth boom during the pandemic proved virtual primary care inspires several value-ads.

Telemedicine

Telemedicine Primary Care Regulations Doctors

The ‘Strange Tension’ That Exists Between Consumer-Directed Models, Regulations Surrounding Them

Home Health Care

FEBRUARY 13, 2024

However, there is a tension that exists between the demand for those alternative care models and the regulations from the federal government that could drastically affect them. Regulatory tension Medicare covers home health care, but not personal care, which generally helps seniors deal with activities of daily living.

Regulations

Regulations Home Care Law Firms Medicaid

CMS floats 1.25% physician fee cut, 2.8% outpatient bump in new proposed rules

Health Care Dive

JULY 14, 2023

Regulators also proposed stricter price transparency requirements on hospitals and expanded behavioral health payments in Medicare.

Regulations

Regulations Medicare Hospitals

How Will New FDA Hearing Aid Regulations Impact Health Plans?

HIT Consultant

NOVEMBER 24, 2022

The Food & Drug Administration’s new over-the-counter (OTC) hearing aid regulations are now in effect and health plans are starting to explore what it means for them. The regulations may provide an opportunity for health insurers to attract new members – and retain existing ones – with hearing loss. Expanding membership.

Regulations

Regulations Medicare Quality of Care Integration

HHS proposes ‘powerful’ penalties for providers found information blocking

Health Care Dive

OCTOBER 31, 2023

Regulators on Monday proposed a long-awaited rule tying payments for hospitals and doctor’s offices in three popular Medicare programs to compliance with data-sharing regulations.

Regulations

Regulations Doctors Medicare Hospitals

Revitalizing Medicare Advantage: How The Push to Streamline Prior Authorization Will Impact Senior Care

HIT Consultant

NOVEMBER 21, 2024

Some regulations focus on specific portions of the prior authorization process, while others zero in on certain health plans. Recently, a bipartisan group of lawmakers reintroduced legislation to overhaul the prior authorization process of Medicare Advantage plans. However, the practical implementation of these rules remains a concern.

Medicare

Medicare Regulations Accountability Prevention

Code Red: Healthcare Cybersecurity in a Post-Chevron World

HIT Consultant

OCTOBER 22, 2024

This provided agencies with broad discretion to create and enforce regulations that often filled gaps left by legislators. Implications for Cybersecurity in Healthcare Vulnerability of Existing Regulations The immediate impact of this ruling is the increased vulnerability of existing cybersecurity regulations to legal challenges.

Healthcare

Healthcare Regulations Medicaid Medicare

Kaiser, Mayo, Medically Home found coalition to promote advanced hospital-at-home services

Healthcare It News

OCTOBER 14, 2021

"The pandemic winding down is great from a public health standpoint, but we know Congress doesn't want to just open the floodgates" with no virtual care regulations. The coalition's perspective, he said, is that regulators should "put guardrails on, but let us continue the good work."

Hospitals

Hospitals Home Care Regulations Medicaid

CMS, HHS can use existing federal authority to regulate AI safety in hospitals: JAMA

Remote patient monitoring in Medicare needs more oversight: OIG

Trending Sources

Medicare Advantage risk assessments driving billions in costs each year

AHIP 2024: Cutting through the 'nostalgia' for traditional Medicare

CMS to get ‘tougher’ on Medicare Advantage, official promises

CMS to lower importance of ‘call center’ metric in Medicare Advantage star ratings

OIG report suggests telehealth fraud rare in Medicare

CMS finalizes 2024 Medicare hospital, doctor payments, 340B fix and price transparency requirements

Medicare Advantage lobby rebuts senator’s inquiry into ‘potentially deceptive’ marketing tactics

Elevance sues HHS over Medicare Advantage star ratings

SCOTUS rejects UnitedHealth appeal of Medicare Advantage overpayment rule

Lobby-funded study argues Medicare Advantage rate cuts are worse than CMS expects

Centene sues HHS over Medicare Advantage star ratings fall

Private equity deals in MA are declining, but experts say regulators should keep an eye on this space

CMS recalculates Medicare Advantage star ratings in major win for insurers

HHS OIG backs nixing capital cost exemption for new hospitals

Medicare Advantage plans could see rates dip slightly in 2025

CMS ordered to recalculate UnitedHealthcare’s 2025 MA stars

CMS sets Medicaid payments to home care workers at 80%

Low-income seniors more likely to report fraudulent marketing from private Medicare plans, survey finds

Elevance Health sues HHS over Medicare Advantage star ratings

Private equity deals in Medicare Advantage decline, report finds

Congress reaches spending deal with doc pay bump, delayed DSH cuts and more

CMS proposes 2.9% cut to physician pay for 2025

CMS to crack down on Medicare Advantage audits, poised to claw back billions of dollars from insurers

J.D. Power: MA plans beat commercial coverage on consumer satisfaction

CMS exploring models centered on social health factors

Amedisys’ Medicare Advantage Gains Outpace Traditional Medicare Losses

What Home Health Providers Need To Know About CMS’ Medicare Enrollment Changes

CMS tweaks ACO REACH to stabilize model

Reimbursement Insights: Medicare and Medicaid Coverage for Cardiology Billing

Putting 2024’s Split/Shared Services Billing Regulations into Practice

New Medicare Marketing Definition

EHNAC and CARIN Alliance launch new accreditation program

Regulation as a Catalyst for Innovation: Leveraging the Interoperability and Prior Authorization Mandate

Final Medicare Overpayment Rules a Mixed Bag for Providers

Primary care practices identify needed improvements for telemedicine

The ‘Strange Tension’ That Exists Between Consumer-Directed Models, Regulations Surrounding Them

CMS floats 1.25% physician fee cut, 2.8% outpatient bump in new proposed rules

How Will New FDA Hearing Aid Regulations Impact Health Plans?

HHS proposes ‘powerful’ penalties for providers found information blocking

Revitalizing Medicare Advantage: How The Push to Streamline Prior Authorization Will Impact Senior Care

Code Red: Healthcare Cybersecurity in a Post-Chevron World

Kaiser, Mayo, Medically Home found coalition to promote advanced hospital-at-home services

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