COVID-19 has brought uncertainty and fear into the lives of Americans and the world, and we have seen the country come to a screeching halt in order to slow the spread of this novel coronavirus. Due to the overwhelming increase in COVID-19 infections in long-term care facilities throughout the United States, the Center for Medicare and Medicaid Services (CMS), which is responsible for ensuring the health and safety of nursing home residents, recently issued a memorandum outlining new guidelines for nursing homes to help control and prevent the spread of the disease. The CMS is working hand-in-hand with the Center for Disease Control (CDC) to provide nursing homes with guidance how to keep residents safe.
We provide insights and analysis for physicians, nurses, chiropractors, dentists, physical therapists and other health professionals on issues impacting their practices.
The Centers for Medicare & Medicaid Services (CMS), The Health and Human Services Department (HHS), as well as other health related federal agencies, have continued to waive requirements, or expand services and benefits in an effort to help contain the COVID-19 virus.
Building upon the bundled payment demonstration programs currently underway for Medicare, the Centers for Medicare and Medicaid Services (CMS) announced a proposal for a major shift in the way hospitals will be paid for hip and knee replacements. In an effort to incentivize hospitals to encourage quality and care improvements as patients transition from surgery to recovery, CMS proposed a change in the manner of payment to focus on episodes of care, rather than a piecemeal system.
On April 2, 2015, CMS issued notice of imposition of a $1 Million civil money penalty (CMP) against Aetna for errors reported in Aetna’s pharmacy network directory. Due to this error, many Aetna enrollees presented prescriptions to their pharmacy, only to discover that the pharmacy was not in their plan. The Medicare enrollees complained to CMS resulting in over 33% of all complaints received by CMS, of which 73% of those complaints alleged the beneficiaries were misled about in-network pharmacy coverage by Aetna’s marketing. CMS based its CMP on Aetna’s failure to disseminate clear and accurate information about the number, mix, and addresses of network pharmacies from which the Medicare enrollees could obtain covered Part D drugs. In addition, Medicare beneficiaries enrolled in Aetna’s plan have been given a special enrollment period to disenroll from Aetna’s plan and reenroll in another Part D plan. A copy of the April 2, 2015 CMS notice to Aetna is attached.
CMS has ordered the Medicare Administrative Contractors (MACs) to re-review all denied claims for admissions under the “two-midnight” rule. The Final Rule CMS-1599-F has proven to be difficult to implement. On 2/24/14, CMS issued new guidance, whereby CMS is waiving the timeframe for filing redetermination requests for appeals received before 9/30/14 for claims denied before 1/30/14 under the Probe and Educate process. The MACs are re-reviewing all claim denials under the Probe & Educate process to ensure claim decisions and education is consistent with recent clarifications from CMS. With CMS calling for the MACs to re-review denied “two midnight” admissions, documentation of medical necessity remains important.