Extension for Licensure of One Room Centers

The New Jersey Assembly recently proposed Bill No.1989 extending the effective date for one room centers to become licensed to July 1, 2020, citing staffing and resource limitations.  We will keep track of this bill along the legislative process, and inform you if and when the bill passes both houses and is approved by the Governor.

New Jersey and Federal Legislative Update

New Jersey Statutes:

A3717 – Approved – We previously reported on this statute, which initially passed both houses, but was then vetoed by the Governor.  After some modifications, the statute passed both houses again and became law after excluding self-insured plans, the State Health Benefits Plan, and the School Employees Health Benefits Plan.  The statute prohibits a pharmacy benefits manager from retroactively reducing payments on a properly filed claim for payment by a pharmacy.

Legislative and Litigation Update

New Jersey State Regulatory Issues

51 N.J.R. 1806(a) – Notice of Action on Petition for Rulemaking

The Department of Health received a petition to make amendments to N.J.A.C. 8:43G, the Hospital Licensing Standards, in Subchapter 14 Infection Control, at N.J.A.C. 8:43G-14.9, Sepsis protocols.  We previously reported that the Department confirmed receipt of the petition.  At this time, the Department has not decided on the petition and has referred the petition to the Division of Certificate of Need and Licensing to evaluate, and make recommendations as to the appropriateness of granting the petition.

Eleventh Circuit Raises the Bar on the False Claims Act.

The Eleventh Circuit dealt a win for providers in United States v. AseraCare, ruling that a mere difference of clinical opinion among physicians is not enough to prove “falsity” under the False Claims Act.  The Eleventh Circuit’s decision emphasizes that reasonable differences of opinion between physician reviewers of medical documentation are not sufficient to suggest that the judgments concerning a particular patient’s eligibility for Medicare’s hospice benefit, or any claims submitted based on such judgments, are false for purposes of the False Claims Act.

Regulatory Update, Including Federal Transparency Rules

Federal Regulations

Pricing Transparency Rules:  As previously reported on November 22nd, we anticipated that the Department of Health would publish the transparency rules in the Federal Register on November 27th.  Today, the Department of Health published in the Federal Register the final Rule requiring hospitals to disclose pricing information and the proposed Transparency in Coverage Rule requiring insurers, among other things, to disclose cost-sharing information. 

Anticipated Federal Hospital and Payor Transparency Rules

As we previously reported, on November 15, 2019, CMS issued a final rule and comment period that revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year 2020. In that final rule, CMS made clear that it intends to continue with its policy to require hospitals to publicly disclose "standard charges," including payer-specific negotiated rates.  CMS, however, did not actually publish the final rule in the registry and, instead, CMS stated it “received over 1,400 comments on our proposed requirements for hospitals to make public their standard charges.

Federal Regulatory Update

Ambulatory Surgery Center Prospective Payment System

84 FR 61142 – Final Rule with Comment Period – This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year (CY) 2020.  On average for all covered procedures in ASCs, payment rates went up by 2.6%.