Compliance & Legal

With millions of Americans on new health insurance exchange plans now responsible for high deductibles, hospitals, drug makers, insurers and regulators are entering a new frontier of payment disputes.

With the Massachusetts Attorney General granting Partners Healthcare System a long-term lease on life as the dominant provider in Eastern Massachusetts, it's almost certain that the state and its residents will continue to pay above-average healthcare costs.

Medicare may be overpaying hospitals an estimated $5 billion as a result of the 18-month moratorium on enforcing the controversial two-midnight rule that tells hospitals when patients should be admitted, according to an independent Medicare auditing company.

A new interpretation of a 40-year-old law could offer healthcare providers more options for appealing payer recoupments or preventing them altogether.

Last week, the Centers for Medicare & Medicaid Services published a final rule that reforms federal health policy regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on healthcare providers and suppliers. Here are some highlights.

The proposal for next year's Medicare inpatient payments to hospitals continues the pressure on them, and doubles down on a controversial policy.

Hospitals of all sizes are looking for partners. But the quest to increase market share by acquiring physician groups or other hospitals is drawing critical analysis from regulators, particularly if a merger results in eliminating a competitor.

Hospitals are educating their staff and reworking their processes to comply with Medicare's two-midnight rule, which will likely reduce hospital revenue by shifting patients from inpatient to outpatient status.

Last week's ruling in the case of ProMedica Health System vs. the Federal Trade Commission offers key lessons for CFOs about how hospitals and health systems should proceed with mergers or acquisitions.

The newly available data on Medicare physician reimbursement may bolster would-be whistle-blowers, but health systems and medical practices can get ahead of the issue.