Georgia's Trusted Healthcare
& Medical Provider Attorneys

CMS Proposes Changes In Rules For CMOs

For the first time in more than a decade, the Centers CMOfor Medicare and Medicaid Services issued proposed changes in rules affecting Care Management Organizations

On June 1, 2015, the Centers for Medicare and Medicaid Services (“CMS”) published a proposed rule affecting Care Management Organizations (CMOs) that administer Medicaid benefits.  This is the first major overhaul of the managed care system since 2002.  Most believe these changes are long overdue as CMOs now cover approximately 74 percent of all Medicaid enrollees making managed care the dominant delivery system for Medicaid.

According to CMS, the Proposed Rule will “improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage.”

The Rule targets seven main areas:

  • Improvement of the beneficiary’s experience
  • State delivery system reform
  • Quality improvement
  • Program and fiscal integrity
  • Managed long-term services and supports (MLTSS) programs
  • Children’s Health Insurance Program (CHIP)
  • Alignment with Medicare Advantage and Private Coverage Plans

Public comments are due July 27, 2015. CMS has published a Fact Sheet outlining the Proposed Rule that can be found here.

We urge CMOs to familiarize themselves with the Proposed Rule and take advantage of the time period for public comment. If you have any questions involving the Proposed Rule, please contact Kimberly Sheridan at 678.325.3872.

 

Healthcare Providers Could See an Increase in Centers for Medicare and Medicaid Services Audits

On June 2012, the Department of Justice (DOJ) issued a report from its study of Home and Community Based Services (HCBS) waiver programs.  Seven of 25 states reviewed were found to have systems that were lacking in their ability to provide quality care to waiver program recipients.  In addition, the study found that the Centers for Medicare and Medicaid Services (CMS) did not use all means available to monitor the states’ programs.  As a result, the DOJ recommended that CMS implement additional requirements to ensure quality care.

Going forward, states may see more involvement and oversight on the part of CMS in enforcing compliance with the requirements of the HCBS waiver programs.  The increased attention paid by CMS could mean more site visits, audits, and compliance initiatives aimed at providers.  As with any audit or proposed adverse action, it is always to the provider’s benefit to consult with an experienced healthcare attorney immediately upon receipt of notice of an upcoming audit, audit results or overpayment demand letters.  The attorneys at Jeyaram & Associates have in-depth audit experience and are available for consultation.