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On January 9, 2024, the federal Centers for Medicare and Medicaid Services (CMS) finally approved New York State’s 1115 waiver amendment to establish the New York Health Equity Reform (NYHER) Program. That application, which is the successor to the state’s Delivery System Reform Incentive Payment (DSRIP) Program that expired in March 2020, was first described in a concept paper issued by the Department of Health (DOH) in August 2021, and was filed with CMS in September 2022. The approved waiver amendment, which expires on March 31, 2027, includes most of the features included in the original application, but not all.

The overall goals of NYHER include:

  • Health-Related Social Needs: Investments in health-related social needs (HRSN) via greater integration between primary care providers and community-based organizations, with a goal of improved quality and outcomes.
  • Health Equity: Improving quality and outcomes of enrollees in geographic areas that have a longstanding history of health disparities and disengagement from the health system, including through an incentive program for safety net providers with exceptional exposure to enrollees with historically worse health outcomes and HRSN challenges.
  • Integrated Care: Focus on integrated primary care, behavioral health, and HRSN with a goal to improve population health and health equity outcomes for high-risk enrollees, including kids/youth, pregnant and postpartum individuals, the chronically homeless, and individuals with substance use disorder (SUD).
  • Workforce: Workforce investments with a goal of equitable and sustainable access to care in Medicaid.
  • Regional Approaches: Developing regionally focused approaches, including new value-based purchasing (VBP) programs, with a goal of statewide accountability for improving health, outcomes, and equity.

These goals are embodied in four new initiatives: (1) HRSN, (2) a Health Equity Regional Organization (HERO), (3) Medicaid Hospital Global Budget Initiative, and (4) Strengthen the Workforce. Each will be examined in turn.Continue Reading CMS Approves a New 1115 Waiver Amendment:  The New York Health Equity Reform (NYHER) Program

As we have discussed in an earlier blog post, the federal administrative agencies have been placing greater emphasis on being more transparent and promoting “interoperability”.

As such, on April 24, 2018, the Centers for Medicare & Medicaid Services (“CMS”) proposed changes to its Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System to promote better access to…
Continue Reading Seeking Interoperability: Centers for Medicare & Medicaid Services

imagesNG7ROJJTCMS has published a Proposed Rule to clarify how physicians are to bill for services furnished “incident to” the professional services of a physician.

When a medical practice bills Medicare “incident to” for NPP services (i.e. “non-physician practitioners” such as nurses or physician assistants), the bill is rendered by the physician using the physician’s NPI number. Incident to services billed…
Continue Reading ‘Incident To’ Billing: Billing Physician as the Supervising Physician and Ancillary Personnel Requirements

When does the 60-day clock start for an identified overpayment of federal funds to become a reverse false claim under amendments to the False Claims Act?  A closely watched SDNY qui tam  case may provide an answer. 

In June, the United States and New York intervened in United States v. Continuum Health Partners, Inc., alleging that defendants had knowingly…
Continue Reading Dismissal Motions Filed In SDNY Computer Glitch Reverse False Claim Act Case

At the end of June, the U.S. Attorney’s Office in Manhattan filed a False Claims Act complaint against Beth Israel Medical Center, St. Luke’s-Roosevelt Hospital Center, and Continuum Health Partners, United States v. Continuum Health Partners, Inc., alleging that defendants had knowingly failed to return overpayments owed to Medicaid arising out of a computer glitch. 

In 2010, the…
Continue Reading Failure To Promptly Return Overpayments Arising From Computer Glitch Leads To False Claims Act Complaint

DOE-logoA recent SDNY False Claims Act decision provides strong support for the argument that a false claim may not be based on conduct that follows federal or state rules and guidelines. 

In United States ex rel. Doe v. Taconic Hills Central School District, relators alleged that the New York City Department of Education (“DOE”) and several school districts submitted…
Continue Reading False Claims Act Complaint Dismissed Where Defendant Followed State Regulations

At the end of January, the Office of Inspector General for the Department of Health and Human Services (“HHS-OIG”) released its 2014 Work Plan.  The Work Plan summarizes new and ongoing reviews and activities that HHS-OIG plans to pursue with respect to HHS programs and operations in the coming year. 
 

Senior HHS-OIG officials outlined agency goals in a video…
Continue Reading HHS-OIG 2014 Work Plan Focuses On Health Insurance Transitions

In U.S. ex rel. Wolfson v. Park Avenue Medical Associates, the U.S. Attorney’s Office in the Southern District of New York entered into a $1 million False Claims Act settlement against three related companies for improperly billing Medicare for behavioral health services.  The settlement agreement provided that the defendants “admit, acknowledge and accept responsibility for” (1) billing Medicare for …

Continue Reading Admission of Wrongdoing Requirement May Make SDNY Less Attractive to Qui Tam Relators

patient entering MRI machineA bill proposed in the US House of Representatives may cause physicians to significantly restructure their practices as they relate to in-office ancillary services (IOAS).

Promoting Integrity in Medicare Act of 2013

The Stark Law is a federal statute which prohibits physicians from making referrals for Medicare-covered designated health services (DHS) to an entity with which the physician or an…
Continue Reading Bill Could Narrow Stark Law Exception for In-Office Ancillary Services

A post on the KevinMD blog written by Bob Doherty, Senior VP of the American College of Physicians, says that regardless of who wins the 2012 Presidential election, the fee-for-service payment methodolgy to physicians under Medicare may be dead.

The health reform proposals from President Obama and Governor Romney approach Medicare from different angles, but each may end up killing…

Continue Reading Is Medicare Fee for Service Dead?