News & Press

U.S. Supreme Court Weighs In On Patients' Right to Freedom of Choice of Providers

Thu, 24 Jul 2025 04:05:00 GMT

Dear Kelly,

The following article is about a recent decision from the U.S. Supreme Court about patients' right to freedom of choice.

If you decide to use this material, please include our copyright designation that is shown at the end of the article and send us a copy of any publication in which the material appears.

The right of patients to choose providers who will render care to them is currently based on four key sources:

Court decisions that establish the right of all patients, regardless of payor source and the setting in which services are rendered, to control treatment, including who provides it
Federal statutes for both the Medicare and Medicaid Programs that establish the right of patients whose care is paid for by these programs to choose providers to render care - Specifically, Section 1802 (42 U.S. C. 1395a) states as follows: “(a) Basic freedom of choice.- Any individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency or person undertakes to provide him such services.”
The Balanced Budget Act of 1997 (BBA), which currently requires hospitals to provide a list of home health agencies and hospices to patients. According to the BBA, the list must meet the following criteria: (a) Providers that render services in the geographic area in which patients reside, are Medicare-certified, and request to be included must appear on the list given to patients. (b) If hospitals have a financial interest in any provider that appears on the list, this interest must be disclosed on the list.
Conditions of Participation (COP’s) of the Medicare Program that are the same as the provisions of the BBA described above

The U.S Supreme Court has now issued a decision about the federal statute for the Medicaid Program described above in Medina v. Planned Parenthood South Atlantic, et al. [No, 23-1276 (June 26, 2025)]. This case involves the any-qualified-provider provision in the statute above that requires states to ensure that any individual eligible for medical assistance may obtain it from any provider qualified to perform the service who undertakes to provide it. The question is whether individual Medicaid beneficiaries may sue state officials under the above statute for failing to comply with the any-qualified-provider provision.

The State of South Carolina excluded Planned Parenthood from the Medicaid Program. An enrollee in the Medicaid Program sued the State based on the above statute because she said that she wanted to receive Medicaid services from Planned Parenthood.

The Court said that spending power statutes, such as Medicaid Programs, are especially unlikely to create the right for individuals to sue the states. The typical remedy for state noncompliance is federal funding termination. Private enforcement, such as suits by individuals, requires states to voluntarily and knowingly consent to private suits based on clear and unambiguous alerts from Congress to the states that private enforcement is a funding condition.

The Court concluded that the above statute does not permit individuals to sue the States for violation of their right to freedom of choice of providers.

©2025 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Medicaid Fraud

Thu, 17 Jul 2025 05:00:00 GMT

Some owners and managers of home health, hospice, home care/private duty agencies, and HME companies mistakenly think that fraud and abuse prohibitions apply only to services paid for by the Medicare Program. In fact, fraud and abuse prohibitions apply to providers if they accept any state or federal funds, including, but not limited to, Medicaid, Medicaid waiver, VA, and Tri-Care. In addition, many private insurers have adopted the prohibitions on fraud implemented by state and federal programs.

Private duty home care agencies and home health agencies that provide services to Medicaid and Medicaid waiver patients are increasingly in the crosshairs of fraud enforcers, The reason for enhanced scrutiny is that both the federal government, which partially funds state Medicaid and Medicaid Waiver Programs, and state governments that also fund these programs are alarmed about the high costs of fraud, abuse, and waste.

Conventional wisdom says that there are big bucks to be saved if fraud and abuse in the Programs are controlled and ultimately eliminated. Conventional wisdom also says that enforcement actions in Medicaid Programs have just scratched the surface. According to this “wisdom,” there are big bucks to be recouped from “low-hanging fruit!”

A recent report from the Office of Inspector General of the U.S. Department of Health and Human Services seems to support this perception regarding private duty home care agencies based on the following:

Between 2014 and 2023, at least 34% of fraud convictions in some years were based on private duty home care services. In some years, this percentage was as high as 48%.
In fiscal year 2023, there were 279 criminal convictions related to private duty home care services compared to 66 for registered nurses and 43 for home health agencies.

Here are some recent examples of “low-hanging fruit” in private duty home care agencies from the 2025 National Healthcare Fraud Takedown, including billing for:

Services provided while the client was in Jamaica for six months
Visits cancelled in advance by clients
Services while the caregiver was on vacation in a foreign country
Care provided while the caregiver was working another job

The feds are certainly convinced that Medicaid expenses must be cut and that there is a lot of fraud and abuse in the Medicaid Program. Now is the time for providers to be more vigilant than ever!

©2025 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Who Can Perform a Face-to-Face Encounter

Wed, 14 May 2025 20:29:00 GMT

The face-to-face encounter must be performed by one of the following:

The certifying physician or a physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health
The certifying nurse practitioner, certifying clinical nurse specialist, or a nurse practitioner or clinical nurse specialist who is working in accordance with state law and in collaboration with a physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health

If a beneficiary was admitted from home and the certifying provider and the face-to-face performing provider are different:

A community provider can perform the face-to-face even if they are not the certifying provider
Evidence of collaboration must be included in the documentation which verifies that prior to the certification, the certifying provider collaborated with the provider who performed the face-to-face
No evidence of collaboration is required if it can be determined that the certifying provider and the provider who performed the face-to-face are from the same practice

click here to learn more

Relief for Providers from Devastating Penalties?

Fri, 11 Apr 2025 15:59:00 GMT

A judge in the Northern District of Texas recently decided that even the minimum penalties mandated under the False Claims Act (FCA) violate the Eighth Amendment’s Excessive Fines Clause [see U.S. ex rel. Taylor v. Healthcare Associates of Tex. (N.D. Tex. Feb. 26, 2025)]. The FCA punishes providers for submission of information that is not true in order to get paid by the federal government.

The penalties assessed against providers under the FCA may be described as “life threatening.” That is, it may be difficult for providers’ businesses to survive payment of such severe penalties. The minimum penalty increased from $13,946 to $14,308 in 2025. The maximum penalty per claim increased from $27,894 to $28,619. These increased penalties will be assessed for violations that occurred prior to the change, but that are assessed after they are in effect. These penalties certainly make it clear why it is difficult for providers to survive violations of the FCA.

In the Taylor case above, for example, the defendants allegedly submitted false claims as follows:

•    As “incident to” a physician’s care without proper documentation
•    For services by providers who were not eligible to bill the Medicare Program
•    For services performed by medical assistants instead of qualified practitioners

The jury found that one of the defendants, a primary care medical group practice, submitted 21,944 false claims for $2,753,641.86 in actual damages. After trebling the damages as required by the FCA, the Court said it would enter judgement against the defendant for approximately $8 million. The Court acknowledged, however, that penalties under the FCA are fines subject to the Eighth Amendment of the U.S. Constitution.

The Court then applied the following four factors to decide whether the “fine was grossly disproportional to the gravity of the offense” under the Eighth Amendment:

1.    The essence of the defendant’s crime and its relationship to other criminal activity
2.    Whether the defendant was within the class of people for whom the statute of conviction was principally designed
3.    The maximum sentence, including the fine that could have been imposed
4.    The nature of the harm resulting from the defendant’s conduct

With regard to the first factor, the Court emphasized that the defendant’s misconduct involved violations of Medicare billing rules, but did not include billing for services that were not provided. In fact, the Court said that even though the defendant violated Medicare billing rules, the misconduct was “closer in gravity to something like a ‘reporting offense.’” There was, said the Court, no evidence that the defendant’s conduct was “related to other criminal or fraudulent activity.

The Court also focused attention on the fourth factor. The defendant’s harm was certainly significant, but the harm, according to the Court, did not necessitate a penalty “two orders of magnitude greater than the actual financial harm,” especially when the actual damages were substantial, i.e., one hundred times the amount of actual damages. That ratio was “grossly out of alignment with the ratios in other similar cases.” The Court imposed a civil penalty of $8,260,925.58 that represents less than 3% of the statutory minimum.

Whether other Courts follow the Taylor case described above remains to be seen, but it is quite clear that providers need relief from the penalties of the FCA.

©2025 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Gaslighting Patients and Caregivers

Wed, 26 Mar 2025 16:01:00 GMT

According to Nurse Professional Liability Exposure Claim Report: 4th Edition issued by Nurses Service Organization and CNA, for the period from 2016 to 2019 nurses who provided services to patients in their homes; including those providing home health and hospice, and palliative care; were the most vulnerable of all nursing specialties to professional liability claims. This is the first time that nurses in home care topped the list since the reports were first compiled in 2008. Home care nurses accounted for 20.7% of claims, which represents an increase of 12.4% over the previous number reported in 2015.
Adult medical/surgical nurses topped the list in past reports.

These factors may contribute to increases in claims against home care nurses:
•    Lack of institutional support for home care nurses that is routinely received by nurses in hospitals and other facilities
•    Growing popularity of home care
•    Rising acuity of home care patients
•    Lack of 24-hour oversight of patients
•    Absence of equipment in patients’ homes that is readily available in institutional settings to help identify patients at high risk for negative outcomes

However, the nonprofit organization Emergency Care Research Institute (ECRI) says that eroding trust is a major threat to patient safety in 2025. ECRI ranks “gaslighting,” or dismissing concerns of patients and caregivers, as the top issue. In other words, nurses aren’t listening to patients and their caregivers! There is an old adage that says that if practitioners would just listen to their patients, patients will tell them what is wrong (i.e., the diagnosis). Perhaps, then, the best way to avoid negligence and resulting lawsuits is to listen to patients and caregivers.

Other strategies that nurses can use to protect themselves from malpractice claims include:
•    Stay up to date on education and training
•    Document assessments of patients in a timely and objective manner
•    Go up the chain of command when concerned about the well-being of patients
•    Maintain files that demonstrate character; such as letters of recommendation, notes from patients, and performance evaluations

Of course, complete, accurate and contemporaneous documentation may provide the best defense of all!

An increase in malpractice claims against home health and hospice nurses is a significant new industry development. It’s time to move risk management, with a focus on listening to patients and caregivers, higher up the list!

©2025 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

CMS Leadership on Historic Announcement of First Selected Drugs for Medicare

Fri, 1 Sep 2023 00:34:00 GMT

For the first time, Medicare is able to directly negotiate the prices of prescription drugs due to President Biden’s lower cost prescription drug law, the Inflation Reduction Act. Today, leaders of the Centers for Medicare & Medicaid Services (CMS) issued the following statements on the historic announcement of the first 10 drugs covered under Medicare Part D selected for negotiation under the Medicare Drug Price Negotiation Program. The negotiations with participating drug companies for the selected drugs announced today will occur in 2023 and 2024 with the negotiated prices effective beginning in 2026. In addition, CMS is announcing more information about patient-focused listening sessions on the selected drugs with interested parties that will occur in Fall 2023.

“Today marks a significant and historic moment for the Medicare program with the announcement of the first drugs selected for Medicare drug price negotiation,” said CMS Administrator Chiquita Brooks-LaSure. “Our goal with these negotiations is to improve access to some of the costliest drugs for millions of people with Medicare while driving competition and innovation.”

“Promoting transparency and engagement continue to be at the core of how we are implementing the new drug law and the Medicare Drug Price Negotiation Program, and that is why we set out a process for the first round of negotiation that engages the public throughout,” said Meena Seshamani, MD, PhD, CMS Deputy Administrator and Director of the Center for Medicare. “Along with the announcement of the selected drugs, we announced CMS’ plans to host a patient-focused listening session for each selected drug to hear directly from patients and others.”

This announcement is one of a number of steps CMS previously detailed in the Medicare Drug Price Negotiation Program timeline for the first cycle of negotiation. Other key upcoming dates for implementation include:

October 1, 2023: Deadline for companies with a drug selected for the Negotiation Program to choose whether to sign agreements to participate in the negotiation process for 2026.
October 2, 2023: Deadline for participating companies with a drug selected for the Negotiation Program to submit manufacturer-specific data for CMS to consider in the negotiations. In addition, this is the deadline for the public to submit data on therapeutic alternatives to the selected drugs, data related to unmet medical need, and data on impacts to specific populations.
Fall 2023: CMS will invite each participating drug company with a selected drug to engage in a meeting on its data submission. CMS will also hold a patient-focused listening session for each selected drug. The patient-focused listening sessions, which will include participation from patients, beneficiaries, caregivers, consumer and patient organizations, and other interested parties, will be held between October 30, 2023 and November 15, 2023. The listening sessions are subject to change, including postponement and/or cancellation.
February 1, 2024: CMS sends an initial offer of a maximum fair price for a selected drug with a justification to each drug company participating in the Negotiation Program.
August 1, 2024: The negotiation period ends.
September 1, 2024: CMS will publish the maximum fair prices that have been negotiated for drugs selected for negotiation for 2026.

View the HHS press release.

View a fact sheet on the drugs selected for the Medicare Drug Price Negotiation Program, as well as more information about the patient-focused listening sessions.

More information on the patient-focused listening sessions is available at https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation-program-patient-focused-listening-sessions.

More information on the Medicare Drug Price Negotiation Program is available at https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation.

NHPCO and NAHC Boards Agree to Pursue Creation of a New, Combined Organization

Fri, 11 Aug 2023 00:44:00 GMT

Newly Created Organization Would be Stronger Voice to Represent the Spectrum of Home and Community-Based Healthcare Providers

(Alexandria, VA and Washington, DC) – The Boards of the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO) agreed to a joint process to explore the formation of a new organization to combine the strengths of both NAHC and NHPCO and better serve members with a unified voice on behalf of the entire community of hospice, home care, palliative care, serious illness, and other care at home providers.

The Boards of NHPCO and NAHC this week signed a non-binding Letter of Intent to pursue the possible combination of both organizations into a new, as-of-yet unnamed organization. Each Board voted on this course of action following the recommendations of a Steering Committee composed of member and staff leaders from both organizations. The Steering Committee’s recommendations were informed by consultations with members of both organizations. The Committee has been working, with the support of association consulting firm McKinley Advisors, since the March 8, 2023 joint announcement (NAHC website, NHPCO website) that NHPCO and NAHC would explore opportunities for deeper collaboration.

“The American healthcare system is shifting, and home and community-based care options are increasing in a multitude of forms across the country,” said Melinda Gruber, PhD, MBA, CNA, NHPCO Board Chair, and President of Caring Circle/Vice President, South Region, Medical Group and Continued Care of Corewell Health. “With decades of experience in hospice and home care, NHPCO and NAHC members are the long-standing experts, and they are evolving to meet patient needs in a shifting environment. As we look ahead, we see an opportunity for the organizations representing those providers to evolve. In this time of change, we are acting with intention and care to continue meeting the needs of providers, patients, families, and communities well into the future.”

“The collaborative process of the NHPCO and NAHC Boards over the last five months has brought the two organizations closer together,” said Kenneth Albert, R.N., Esq., NAHC Board Chair, and President and CEO of Androscoggin Home Healthcare + Hospice. “In addition to the Board-level discussions, our organizations have been collaborating on multiple advocacy efforts, as well as projects such as the Value of Hospice research. Through these efforts, it has become crystal clear that we can do more on behalf of our members by working together. If the current discussions do not lead to a new, combined organization, the outcome will nevertheless be closer working relationships on behalf of community-based and home care providers.”

In the coming months, the NAHC and NHPCO Boards of Directors will work together, in consultation with member volunteers from both organizations, to determine details of how a consolidated organization could represent the best interests of the combined memberships. The organizations expect this process to take six to ten months. McKinley will continue to support the process as an independent, third-party advisor. To facilitate an effective process, both Boards have decided to suspend elections for new Directors this year.

Congressional Briefing Demonstrates the Value of the Medicare Hospice Benefit

Sat, 29 Jul 2023 00:42:00 GMT

New Research Shows Hospice Produces Better Outcomes, Lower Medicare Costs

(Washington, D.C. and Alexandria, VA) – On Thursday, July 27, a panel of healthcare experts presented groundbreaking new research at a Capitol Hill briefing for Congressional offices, showing that patient use of hospice contributed to $3.5 billion in Medicare savings in 2019, while also providing multiple benefits to patients, families, and caregivers. (Watch a video of the briefing here.)

The study, conducted by NORC at the University of Chicago, is one of the most comprehensive analyses of enrollment and administrative claims data for Medicare patients covered by Medicare Advantage and Traditional Medicare. The study was funded by the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO).

Panelists Dianne Munevar, VP of Health Care Strategy at NORC; Dr. Joseph Shega, Chief Medical Office at Vitas; and Susan Lloyd, CEO of Delaware Hospice, related their vast experience with hospice care, extolling its benefit for patients and their loved ones, and also shared findings which prove that longer hospice stays equate to greater savings for taxpayers and overall, better experiences for patients

Susan Lloyd, CEO of Delaware Hospice shared her personal experience with her mother’s end of life care. “The full benefits of hospice care are realized when the patient and family have the opportunity to engage with the team who provides the support needed wherever they call home. Hospice is not a place, it’s a way of caring for people and their loved ones as they are nearing the end of life,” said Lloyd. “One of the greatest blessings of my life was to be there when my mom died. She was not alone; she was surrounded by love. Hospice made that happen for mom, for me, and my family.”

“There’s a lot of myths and misperceptions about what hospice is and what hospice does because of short stays,” said Dr. Joseph Shega, Chief Medical Officer of VITAS. “So when you have a short stay, the hospice does incredible work to try to meet [patients] where they are to honor their wishes […] but if somebody would have that conversation four, five, six, months earlier, they could have an experience like what Jimmy Carter is experiencing now, where he’s chosen he wants to be at home and there’s no difference in life expectancy between those who enroll in hospice earlier vs. those who don’t. With hospice, you can provide that care at home.”

Key findings from the Value of Hospice study include the following:

NORC estimates that Medicare spending for those who received hospice care was $3.5 billion less than it would have been had they not received hospice care.
In the last year of life, the total costs of care to Medicare for beneficiaries who used hospice was 3.1 percent lower than for beneficiaries who did not use hospice.
Hospice is associated with lower Medicare end-of-life expenditures when hospice lengths of stay are 11 days or longer. In other words, earlier enrollment in hospice reduces Medicare spending even further.
Hospice stays of six months or more result savings for Medicare. For those who spent at least six months in hospice in the last year of their lives, spending was on average 11 percent lower than the adjusted spending of beneficiaries who did not use hospice.
At any length of stay, hospice care benefits patients, family members, and caregivers, including increased satisfaction and quality of life, improved pain control, reduced physical and emotional distress, and reduced prolonged grief and other emotional distress.

(Source: NORC at the University of Chicago)

“The longer the hospice stay, the more the potential savings,” said Dianne Munevar, Vice President of Health Care Strategy at NORC. “Even when hospice care is 89 percent of total cost, spending is still 12 percent lower compared to the non-hospice [patient]. That’s a huge difference and a huge value to Medicare.” Even when hospice stays exceed six months, Medicare still saves money. “The longer the stay across all disease groups…hospice spending was 11 percent lower than the non-hospice users,” explained. Munevar.

A recording of the briefing is available.

###

About NAHC

The National Association for Home Care & Hospice (NAHC) is the voice of home care and hospice. NAHC represents the nation’s 33,000 home care and hospice providers, along with the more than two million nurses, therapists, and aides they employ. These caregivers provide vital services to Americans who are aged, disabled, and ill. Some 12 million patients depend on home care and hospice providers, who depend on NAHC for the best in advocacy, education, and information. NAHC is a nonprofit organization that helps its members maintain the highest standards of care. To learn more, visit nahc.org.

About NHPCO

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest and oldest membership association for providers who care for people affected by serious and life-limiting illness. Our members deliver and expand access to high-quality, person-centered interdisciplinary care to millions of Americans. NHPCO provides education and resources to support that mission. Together with our advocacy partner, the Hospice Action Network (HAN), we serve as the leading voice advancing public policy to improve serious-illness and end-of-life care, while our CaringInfo program provides free resources to educate and empower patients and caregivers. nhpco.org

New Report on Nurse and Home Care Aide Shortage Offers Practical Solutions to Solve the Crisis

Tue, 28 Mar 2023 00:45:00 GMT

Washington, D.C. – The United States is facing an unprecedented crisis in developing an adequate workforce of home care aides and nurses to care for the country’s burgeoning elderly and disabled population. It is estimated that between 2020 and 2030, the number of U.S. citizens 85 years of age or older will double, from the current 2.4 million. Such growth in the U.S. aged population exacerbates the current shortage of caregivers that over 12 million Americans of all ages rely on today. With an annual turnover rate of 64 percent and Medicaid reimbursement that has not kept pace with wage inflation, the result is that patients must wait for badly-needed care as agencies are forced to delay accepting new cases due to a lack of qualified workers.

The National Association for Home Care & Hospice (NAHC) and the Home Care Association of America (HCAOA) have brought together some of the smartest and most experienced industry leaders to create The Home Care Workforce Crisis: An Industry Report and Call to Action. This groundbreaking initiative not only addresses the needs of the nursing and home care aide workforce, but also the supply and demand issues for home based care. This report, told from the perspective of the people on the front lines of this crisis, offers policy recommendations and operational best practices to address the workforce shortage in home-based care.

Leaders from across the home care spectrum came together over the last year to conduct a deep dive assessment of the challenges and possible solutions to the current home care workforce crisis. The charge was to create a solutions-focused document that:

Reflects the home care industry’s response to the workforce shortage.
Presents recommendations to multiple audiences, including policy makers, elected officials, educators, and members of national trade associations.
Quantifies and validates the workforce shortage and commits to making the welfare of DCWs and nurses a top priority of home care employers.
Commits to promoting tangible and concrete steps to mitigate the workforce shortage so that all Americans have access to the most preferred health care delivery — in one’s own home.
Understands and is responsive to the needs of health and long-term care delivery systems in terms of avoidance of costly hospital and nursing home stays and respect for individual choice of care setting.

“The supply of nurses and home care aides is not sufficient to meet the demand for their services, which means America’s most vulnerable population suffers,” said NAHC President William A. Dombi. “Family caregivers are already stretched beyond the limit, leading them to take unpaid leave, lose wages, and suffer from care burnout. This also leads people to seek care from costlier settings, such as hospitals and nursing homes. The home care workforce crisis has implications far beyond the care at home community.”

“This report is just the first step to addressing the home care workforce shortage, but it is a significant one,” said Vicki Hoak, CEO of the Home Care Association of America. “It encapsulates the industry’s commitment to elevating the profession of caregiving and urges other stakeholders and policymakers to join us in solving this problem. This week home care providers from both of our associations will be on Capitol Hill meeting with lawmakers to tell their personal stories of the impact this shortage has on families. As the preferred choice of care for older Americans, home care is a lifeline for millions of families with elderly loved ones. But today they are struggling to find the care and support they need. We must continue to stress the urgency of addressing this shortage to meet the massive demand for home-based care from America’s growing aging population by creating a stronger safety net and enabling all Americans to age at home with dignity and respect.”

“Everyone involved in bringing this Call to Action to fruition is thrilled at the result,” says Private Duty Care at NAHC Executive Director Kristen Wheeler. “This report contains actionable steps we as an industry can take, starting now, to effect real change and combat the workforce crisis. The Home Care Workforce Action Alliance, truly a collaboration, shows firsthand that we can no longer work in silos but, together, we can make a difference. It takes a village, and we can succeed!”

The Home Care Workforce Crisis: An Industry Report and Call to Action represents a new and comprehensive look at the direct care workforce crisis and how to solve it. It is the hope of everyone involved that it will help guide the discussion moving forward and provide a framework for all stakeholders to solve the problem and enable America’s elderly and disabled to live independently in the place that they love the most, their own homes.

Visit the official CMS News from the Medicare Learning Network

Thu, 16 Sep 2021 17:40:02 GMT

Thursday, September 16, 2021

News

Compliance

Claims, Pricers, & Codes

Average Sales Price Files: October 2021

Events

National Stakeholder Call with the CMS Administrator — September 17

MLN Matters® Articles

Publications

Multimedia

Part D Coverage Determinations, Appeals, & Grievances Web-Based Training — Revised

View this edition as PDF (PDF)

News

COVID-19 Vaccines: Act Now

CMS announced last week that we’ll require staff within all Medicare and Medicaid-certified facilities to get COVID-19 vaccines. Make efforts now to vaccinate you and your staff so you’re in compliance when the rule takes effect. The higher the level of vaccination rates among you and your staff, the lower the infection rate is for your patients who depend on you for care. Get vaccinated and protect yourselves, your families, and your patients from COVID-19.

More Information:

CDC Benefits of Getting a COVID-19 Vaccine webpage
CDC FAQs about COVID-19 Vaccination webpage: Information and facts, such as how long you’re protected and what is in the vaccine
CDC Vaccinate with Confidence webpage: Resources to help you build confidence in the COVID-19 vaccine
CDC COVID-19 Vaccination for Essential Workers webpage: Why it’s important to get your vaccines and where you can get them
CMS COVID-19 Provider Toolkit: Payment, coding, and billing for vaccine administration

IRF Review Choice Demonstration: Submit Comments by October 8

CMS is continuing the Paperwork Reduction Act (PRA) approval process for the proposed Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration. The required 30-day comment period is open. See the Federal Register Notice for information on how to comment.

Responses and updates from the 60-day public comment period are now available.

Implementation dates for the demonstration depend on PRA approval, the pandemic, and the public health emergency.

Compliance

Medicare Quarterly Provider Compliance Newsletter

Learn about guidance to address billing errors (PDF):

Glucose testing supplies
Bone marrow or stem cell transplant: medical necessity and documentation requirements
Negative pressure wound therapy: medical necessity and documentation requirements

Surgical Dressings: Medicare Requirements

Medicare covers primary or secondary surgical dressings:

Used to protect or treat a wound
If needed after debridement of a wound

The patient’s medical records should include clinical information to demonstrate reasonable and necessary need for the type and quantity of surgical dressings. Providers must evaluate the wound monthly and update the record, unless they document why they can't do a monthly evaluation and how they're monitoring the patient's ongoing use of dressings.

For more information, see the Surgical Dressings – Policy Article .

Claims, Pricers, & Codes

Average Sales Price Files: October 2021

CMS posted the October 2021 Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files and crosswalks on the 2021 ASP Drug Pricing Files webpage.

Events

National Stakeholder Call with the CMS Administrator — September 17

Friday, September 17 from 12:30 to 1 pm ET

You’re invited to join the CMS Administrator, Chiquita Brooks-LaSure, and her leadership team to hear key updates from her first 100 days in office. The Administrator’s vision is for CMS to serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes. We invite you to join us for this first national stakeholder call to learn more about how you can partner with us as we implement our vision.

How to participate:

Join Zoom
Call 833-568-8864 (toll free); webinar ID: 161 910 6718; passcode: 891135

We want to hear from you. Submit questions in advance to Partnership@cms.hhs.gov.

Target audience: national and local stakeholders and partners.

MLN Matters® Articles

2022 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

Learn about automated payments for calendar year 2022 (PDF).

Annual Clotting Factor Furnishing Fee Update 2022

Learn about the $0.239 per unit fee. (PDF)

Home Health Notices of Admission – Additional Manual Instructions

Learn about updates for special billing situations (PDF).

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Health Care (CAQH) CORE

Learn about the next version of the Code Combination List (PDF).

Influenza Vaccine Payment Allowances – Annual Update for 2021-2022 Season

Learn about payment for flu shots. (PDF)

Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

Learn about updates effective October 1 (PDF).

Quarterly Update to Home Health (HH) Grouper

Learn about software updates for the calendar year 2022 final rule (PDF).

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2021 Update

Learn about new and updated codes (PDF).

Publications

DMEPOS Accreditation — Revised

Read new Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier information (PDF) in this Medicare Learning Network fact sheet:

Standards
Enrollment requirements

Independent Diagnostic Testing Facility (IDTF) — Revised

Read new information (PDF) in this Medicare Learning Network fact sheet:

Clarified information on site visits, Section 1877 of the Social Security Act, global billing, separate technical component and professional component billing, skilled nursing facility resident transportation, and mammography services
Added new policy information on the COVID-19 public health emergency and opioid treatment programs
Updated CPT codes for transtelephonic and electronic monitoring services
Get resources to advance health equity and help eliminate health disparities

Multimedia

Part D Coverage Determinations, Appeals, & Grievances Web-Based Training — Revised

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COVID-19 Vaccination Communication Toolkit

Mon, 16 Aug 2021 18:45:31 GMT

Access the toolkit here: https://www.cdc.gov/vaccines/covid-19/health-systems-communication-toolkit.html

New OSHA Emergency Temporary Standard and Its Application to Home-Based Care Providers

Thu, 1 Jul 2021 16:22:51 GMT

Visit: https://www.osha.gov/coronavirus/ets

For more resources.

The ETS was officially filed in the Office of the Federal Register on June 17, 2021, and it became effective when it was published on June 21, 2021.

Written comments on any aspect of the ETS must be submitted by July 21, 2021 in Docket number OSHA-2020-0004 . Written comments on the information collection determination as described in VII.K of the ETS preamble (86 FR 32560) must be submitted by August 20, 2021 in Docket number OSHA-2021-0003 .

Oklahoma Supreme Court Shuts Down Privatized Medicaid

Tue, 8 Jun 2021 22:17:40 GMT

Oklahoma Supreme Court Shuts Down Privatized Medicaid

OKLAHOMA CITY, June 1, 2021 – It’s official: managed care in Oklahoma is unconstitutional. The Oklahoma Supreme Court today issued a 6-3 decision in favor of plaintiffs who alleged that the Oklahoma Health Care Authority (OHCA) overstepped its authority by outsourcing the state’s Medicaid program following the passage of State Question 802.

OHCA announced late last year that the agency would award $2.2 billion in contracts to four insurance conglomerates to run Oklahoma’s expanded Medicaid program.

“The Supreme Court today agreed that the Managed Care contracts were awarded without legislative input and contrary to the plan approved by the voters through State Question 802,” said Lynn Means, executive director, Oklahoma Dental Association. “Medicaid expansion will provide coverage for more than 200,000 of Oklahoma’s most vulnerable citizens. The managed care plan would’ve jeopardized health care for all Oklahomans by driving out providers of general health care, as well as dentists and specialists across the state. This lawsuit was one part of a physician-led effort to ward off privatization to insurance companies and keep Oklahomans in charge of health care in Oklahoma.”

“Oklahoma physicians were virtually united in opposition to this plan,” said Allison LeBoeuf, executive director, Oklahoma Osteopathic Association. “Oklahomans are best served when medical decisions are made between doctor and patient, and without interference from insurance bureaucrats.”

“Pediatricians and family physicians are trusted by their patients because they know how invested their doctors are in patient care,” said Kari Webber, executive vice president of the Oklahoma Academy of Family Physicians and the Oklahoma Chapter of American Academy of Pediatrics. “The Supreme Court decision protects physicians and preserves patient care in Oklahoma.”

“We are pleased with the Supreme Court’s ruling, and we recognize the heart of this issue is much larger than managed care. It’s about ensuring that state agencies follow the law when spending Oklahoma’s tax dollars. Today’s ruling represents an important victory for transparency in government and Oklahoma taxpayers,” said Mary Clarke, MD, president of the Oklahoma State Medical Association.

Plaintiffs on the suit are the Oklahoma State Medical Association, the Oklahoma Dental Association, the Oklahoma Osteopathic Association, the Oklahoma Society of anesthesiologists, Inc., and the Oklahoma Chapter of the American Academy of Pediatrics, Inc., plaintiffs who filed suit to stop managed care on the grounds that the Oklahoma Health Care Authority overstepped its bounds by outsourcing the state’s Medicaid program following the passage of State Question 802.

A copy of today’s Supreme Court ruling can be found here.

More information about the impacts of the proposed managed care plan and the health care providers united against it can be found at www.healthcareholdup.com.

SB388 PASSES AND IS SIGNED INTO LAW!

Thu, 29 Apr 2021 20:06:12 GMT

Read the entire bill here: sb388_enr.pdf

2021 Virtual Senior Day at the Capitol Registration OPEN!

Thu, 25 Mar 2021 21:28:13 GMT

2021_virtual_senior_day_flye.pdf

Share the event and register here: https://alz-org.zoom.us/webinar/register/WN_u2ebGQE1SLyhIYAD-LbxuQ

Medicaid Managed Care: Further Reform Needed to Deliver on Promise

Tue, 23 Mar 2021 21:45:30 GMT

View the Article Here: ajmc_02_2021_zott_final.pdf

Join us in fighting the Healthcare Holdup!

Thu, 18 Mar 2021 16:55:07 GMT

Group aims to stop ‘Health Care Holdup’

OKLAHOMA CITY, March 11, 2021 – A coalition of health care providers and concerned Oklahomans today announced wide-ranging opposition to a flawed scheme to privatize the state’s Medicaid system.

The group is asking Oklahoma legislators to stop the “Health Care Holdup” by halting the governor’s plan to place the system in the hands of insurance companies.

Virtually every aspect of Oklahoma health care is united in opposition to the governor’s plan.

“Oklahoma has been down this road once before, and it was a dismal failure,” said Woody Jenkins, M.D., of Stillwater, co-chair of the Oklahoma State Medical Association Rural Physician Section. “It’s imperative that Oklahomans understand what is about to happen to Oklahoma’s highest-risk populations.”

The effort includes a new website healthcareholdup.com, which describes the rationale for opposition, dispels myths about the promised benefits of privatized Medicaid and instructs Oklahomans how they can assure their voice is heard.

Privatization would limit health care access and would significantly increase the state’s Medicaid administrative costs, which, at less than 5 percent, are among the lowest in the nation.

Opposition to so-called “managed care” comes not only from health care providers, but also from numerous legislators on both sides of the aisle. The combined opposition represents an almost-unprecedented repudiation of any gubernatorial proposal in Oklahoma history.

A similar effort in the 1990s to outsource Oklahoma’s Medicaid program was a failure, and ultimately it was returned to state control.

“Ninety percent of Oklahoma dentists dropped out due to extremely low reimbursement rates imposed by the private insurers. This had a catastrophic effect, particularly on rural Oklahomans and children, as it left less than 100 dentists to treat Medicaid patients,” said Dr. Twana Duncan, whose dentistry practice in Antlers serves several southeastern Oklahoma counties. “I have no doubt this will happen again unless this effort is stopped.”

Concerned Oklahomans are asked to contact their state representative and senator to make their opposition known. Legislative contact information is available at oklegislature.gov.

Members of the coalition include:

Oklahoma State Medical Association
Oklahoma Dental Association
Oklahoma Hospital Association
Oklahoma Osteopathic Association
Oklahoma Society of Anesthesiologists
American Academy of Pediatrics – Oklahoma Chapter
Alliance of Mental Health Providers of Oklahoma
Oklahoma Association of Home Care and Hospice
Oklahoma Psychological Association
Oklahoma Pharmacists Association
Oklahoma Ambulance Association
Oklahoma Nurses Association
Oklahoma Academy of Family Physicians
Leading Age Oklahoma
Oklahoma Medical Equipment Providers Association
American College of Obstetricians and Gynecologists, Oklahoma Chapter
The Arc of Oklahoma

The name of this campaign conveys the “holdup” resulting from privatization: that necessary patient health services and procedures will be either denied or held up. “Holdup” also refers to the governor’s intentional bypass of members of the state Legislature, who are closest to their constituents.

“The Legislature allocates taxpayer dollars, and yet our legislators have not had the opportunity to weigh in on this important decision that impacts their communities,” said Patti Davis, Oklahoma Hospital Association president.

This coalition is not the first opposition to the managed care proposal.

Several physician and dental groups asked the Oklahoma Supreme Court on Feb. 11 to halt the privatization effort until the Legislature can review and approve it. The injunction asks the Supreme Court to determine whether a state board has the authority to commit billions of dollars in future spending without approval of the Legislature, which has the constitutional responsibility of funding state government.

The court has ordered the Oklahoma Health Care Authority to respond by March 15

What Every Clinician Should Know about COVID-19 Vaccine Safety

Mon, 14 Dec 2020 18:13:42 GMT

Date: Monday, December 14, 2020

Time: 1:00 P.M. - 2:00 P.M. (ET)

A few minutes before the webinar starts, please click on the Zoom link below to join: https://www.zoomgov.com/j/1611264903
Or iPhone one-tap:
US: +16692545252,,1611264903# or +16468287666,,1611264903#

Or Telephone: Dial (for higher quality, dial a number based on your current location): US: +1 669 254 5252 or +1 646 828 7666

Webinar ID: 161 126 4903

At the conclusion of the session, the participant will be able to accomplish the following—

Cite background information on the topic covered during the presentation.
Discuss CDC’s role in the topic covered during the presentation.
Describe the topic’s implications for clinicians.
Discuss concerns and/or issues related to preparedness for and/or response to urgent public health threats.
Promote health improvement, wellness, and disease prevention in cooperation with patients, communities, at-risk populations, and other members of an interprofessional team of healthcare providers.

Tom Shimabukuro, MD, MPH, MBA

Vaccine Safety Team Lead

COVID-19 Response

Centers for Disease Control and Prevention

David T. Kuhar, MD

Healthcare Infection Control Team

COVID-19 Response

Centers for Disease Control and Prevention

Project ECHO COVID-19 Call Info

Thu, 30 Apr 2020 20:08:07 GMT

Follow this link to register for the Project ECHO COVID-19 Call.

Every Monday, Wednesday, and Friday at 8:30 am.

https://okstate.forms-db.com/view.php?id=268015