Schedule

Jeff J. Wurzburg, Norton Rose Fulbright US LLP

• A brief history of the Medicaid program and its program objectives
• The statutory requirements for Medicaid programs
• Different state approaches to Medicaid
• The role of managed care in the Medicaid program
• The future of the Medicaid program

Alison Hollender, Husch Blackwell LLP
Kathryn Moore, Bradley Arant Boult Cummings LLP

This session will provide an overview of the key features of Medicare Parts A&B, including the following:

• Reimbursement systems applicable to Part A and B providers
• Governance and structure: CMS, ROs (and the transition to PEOGs), and MACs
• Beneficiary enrollment, coverage, and benefits
• Provider enrollment and certification
• Conditions of participation and payment
• Transactions, demonstrations, and contracting
• Congressional legislation, agency guidance, and key compliance resources

Jesse Berg, Lathrop GPM LLP
R. Ross Burris, Polsinelli PC
Hilary L. Isacson, Assistant General Counsel I, Legal & Risk Services, Sutter Health

• This session will provide an update on key changes affecting Medicare and Medicaid reimbursement that occurred during 2024, including the following:
• New or expanded policy initiatives, such as behavioral health and social determinants of health, implementation of Medicare’s second round of the Drug Price Negotiation Program, CMS’ revised guidance on Rural Emergency Hospitals, continued shifts in telehealth coverage and use of artificial intelligence
• Update on alternative payment models, including updates on the GUIDE (Dementia Care) Model, Oncology Care Model, AHEAD Model, Organ Transplant Access Model, and Final Rule on Appeal Rights for Changes in Inpatient to Observation Status
• Review of key hospital, physician, and other federal provider / supplier payment rules from the 2024 rulemaking cycle, as well as the Mental Health Parity final rule, final changes to Medicare Advantage and actions to remedy underpayments in the 340b drug discount program
• Developments in enforcement and program integrity, including efforts to crack down on improper reimbursement for skin substitutes, new compliance guidance for skilled nursing facilities, updated CMS-855A disclosure requirements, Medicare Advantage marketing issues, the revised overpayment rules, and the future of civil monetary penalties after Jarkesy
• Evolution of AI and digital health regulation from CMS and other agencies
• Reimbursement rule challenges after Loper Bright

Asha B. Scielzo, AHLA President, Director, Health Law & Policy Program, American University Washington College of Law
Emily J. Cook, Planning Committee Chair, McDermott Will & Emery LLP

Robert K. DeConti, Chief Counsel to the Inspector General, Office of the Inspector General, US Department of Health and Human Services

• Session description to follow

Eric Zimmerman, McDermott Will & Emery LLP

• Session description to follow

Karen S. Kim, Athene Law
Dave Yoder, Founder, Medicare Regulatory University

• The hospital cost report, for those not familiar with the form
• The flow of the report, a fundamental understanding of cost-based reimbursement calculations, and how cost reporting disputes result in a large volume of administrative appeals, as well as federal court litigation
• An overview/primer of the appeals and litigation process for cost report disputes
• Timely updates relating to the home office cost report as well as discuss appeals relating specifically to the home office form, wage index, and UC DSH

Timothy P. Blanchard, Blanchard Manning LLP

• A brief review of the Fundamentals
• Medicare Coverage Policies: NCDs and LCDs
• Claims Processing, Overpayment, and Administrative Sanction Risks
• Medicare Advantage Issues
• False Claims and Health Care Fraud Implications

Bradley Cunningham, Lead Policy and Regulatory Analyst, Association of American Medical Colleges
Andrew D. Ruskin, K&L Gates LLP

• Graduate medical education fundamentals
• Optimizing use of opportunities to expand FTE caps
• Protecting a hospital against establishment of a low per-resident amount
• Proper determination of the available bed count
• Status of litigation in relation to all these reimbursement concepts
• Policy considerations under the new administration

Michelle Webb, Senior Practice Attorney, Ascension
Vivian Wozniak, Vice President & Senior Counsel, Texas Children's Health Plan

With over 74% of the Medicaid population enrolled in comprehensive Medicaid managed care organizations (MCOs), network participation agreements and corresponding business relationships with MCOs are a significant component of managed care operations. This session will discuss issues specific to Medicaid managed care from the payer and provider perspective, including:

• A fundamental understanding of the complex regulatory and financial landscape
• Reimbursement        
• Key Contracting considerations
• Alternative Payment Models and Value Based Arrangements

Kelsey Bagheri, Principal Counsel, UC Legal – Office of the General Counsel, University of California
Christine Johnson, Davis Wright Tremaine

• Background
• Policy debates and financial impacts
• Commercial payer conflicts
• What’s next

Marti Arvin, Chief Compliance and Privacy Officer, Erlanger Health
Joseph A. Dickinson, Kaufman & Canoles

• Where compliance and revenue integrity can conflict over the use of AI
• The role of compliance in the selection and deployment of AI solutions for the revenue cycle
• Overview of some of the AI tools used to support revenue cycle
• Key risks associated with the use of AI in the revenue cycle process

Kyle Brierly, Athene Law

• The US Supreme Court’s decision in Loper Bright Enterprises v. Raimondo and its implications for the Medicaid program
• Key federal court decisions affecting Medicaid in the wake of Loper Bright and Talevski
• Other recent and pending Supreme Court cases with significant consequences for Medicaid litigation
• Developments in supplemental payments, financing arrangements, eligibility and benefits under Medicaid
• Litigation involving the authority to implement and oversee Medicaid managed care programs

Richelle Marting, Marting Law LLC; Director of Managed Care Contracting for North Kansas City Hospital

The 2024 Medicare Advantage plan Final Rule raised a number of hot topics affecting both providers and MA plans from prior authorizations, to the use of internal coverage criteria. This session addresses the detailed nuances of the Final Rule critical for plans, health care organizations, and their counsel to know to effectively operationalize CMS requirements. These detailed nuances include:

• When prior authorizations can be used
• Effect of a prior authorization on coverage and payment
• Evolving issues with prior authorizations and post-claim reviews
• Discussion of circumstances when MA plans can develop internal coverage criteria
• Specific requirements for MA plans' internal coverage criteria
• Trending issues between provider organizations and MA plans surrounding coverage criteria

Jeanne L. Vance, Weintraub Tobin

• What is CMMI, what do they do and why?
• What are the current CMMI models being tested?
• How are the models selected?
• What factors should providers consider when deciding whether to participate in voluntary CMMI models?
• Mandatory models and provider issues.

Jonathan Mason, Moss Adams LLP
Stephanie A. Webster, Ropes & Gray LLP

• The impact of the Medicaid redeterminations on Medicare DSH and 340b qualification
• 1115 waiver District Court decision in Baylor All Saints Medical Center
• The struggles/pitfalls (including common MCReF warnings) with the new cost report templates for Medicare DSH, Worksheet S-10, and Medicare Bad Debt
• Federal UC pool trends and report findings from latest round of nationwide S-10 audits
• Status of other pending litigation on the Medicare DSH payment, including challenges to Part C days in pre-10/1/2013 periods, Advocate Christ Medical Center case on days counted as “entitled” in the SSI fraction, Battle Creek case on whether hospitals can appeal directly from CMS’s published SSI fractions, and litigation on capital DSH
• Bridgeport Hospital decision and its impact on the low wage index policy

Mimi Hu Brouillette, WMC Health, Office of Legal Affairs
Nina Adatia Marsden, Hooper, Lundy & Bookman, PC

• Provider Enrollment overview
• Has a Medicare change of ownership (CHOW) occurred? CHOW situations and non-CHOW situations (including hypotheticals)
• Benefits and burdens of accepting v. rejecting automatic assignment of the Medicare provider agreement
• Medicare enrollment and notification requirements related to CHOWs and Changes of Information (CHOIs)
• Medicaid CHOW considerations

Sarah E. Mutinsky, Eyman Associates PC
Anne O'Hagen Karl, Manatt Phelps & Philips LLP

This session will provide an overview of rules governing Medicaid payments to providers, directly and through managed care plans, and critical mechanisms for supplementing and directing Medicaid payments to support policy goals. In addition to an overview of the payment authorities outlined below, we will touch on the latest trends in federal Medicaid provider payment policy, including the major changes to state directed payment rules under the CMS final rule published in May 2024 and its ongoing implementation. Our overview will include the following authorities:

• Medicaid disproportionate share hospital (DSH) payments
• Non-DSH Medicaid fee for service supplemental payments
• Medicaid 1115 demonstration waiver payments
• Medicaid managed care directed payments

Laura Laemmle-Weidenfeld, Jones Day

• Recent developments in CMS’s program integrity efforts
• Recent priorities and developments in HHS-OIG enforcement efforts
• Recent priorities and developments in DOJ civil and criminal enforcement and False Claims Act case law

Marc Hartstein, Principal, Health Policy Alternatives, Inc.
Katrina Pagonis, Hooper, Lundy & Bookman PC

• Inpatient hospital payment update
• Wage index issues
• Disproportionate share and uncompensated care payments
• Transforming Episode Accountability Model (TEAM) demonstration
• New technology add-on payment changes

Susan Banks, Holland & Knight, LLP
B. Scott McBride, Morgan, Lewis & Bockius LLP

• Analyze the January 2025 Overpayments Final Rule and CMS’s new definition of “identified”
• Consider what’s left of judicial deference in the wake of Loper Bright and what this all means (and doesn’t) for providers navigating potential overpayment situations
• Discuss several compliance and overpayment scenarios to assess likely conditions of payment, explore the role of subregulatory guidance, evaluate available deference and rulemaking related defenses, and consider implications for scienter arguments
• Distill practical takeaways for providers conducting internal investigations and defending false claims allegations

Reimbursement and finance professional share a unique set of challenges. Join your reimbursement colleagues to discuss challenges and share solutions.

Kevin D. Smith, Acting Chair, Provider Reimbursement Review Board,Centers for Medicare & Medicaid Services

• Introduction of Board members
• Board decisions
• Jurisdiction
• Hearings
• Case inventory
• Board initiatives
• Board Rules and mandatory electronic filing
• Evaluation of decision process
• Observations from the Board

Grace Feldman, Director, CCBHC Success Center, National Council for Mental Wellbeing (NCMW)
Susannah Gopalan, Feldesman Leifer LLP

• Recent years have seen major expansions in behavioral health coverage in both Medicare and Medicaid. Medicare has traditionally covered a very limited range of behavioral health clinicians’ services and substance use disorder (SUD) interventions, but has expanded its reach to cover more clinicians’ services and a wider range of SUD services. Medicaid is functioning as an engine of change in behavioral health policy, with the certified community behavioral health clinic (CCBHC) model, in particular, gaining national momentum
• In this session, Susannah Gopalan of Feldesman Leifer and a co-presenter from the National Council for Mental Wellbeing will provide a survey of new developments in behavioral health coverage and payment in Medicare and Medicaid. They will discuss how these trends impact various provider sectors, and how medical providers and practices may partner with behavioral health providers in their communities to make these new or expanded services more widely available
• Services and payment methodologies covered will include Medicare intensive outpatient program (IOP) services; Medicare opioid treatment program (OTP) services; the expansion of Medicare Part B-covered behavioral health clinician services; Medicaid CCBHC services; and medication-assisted treatment (MAT) for opioid use disorder in Medicaid
• The presenters will also address the impact of budgetary issues on the expanded behavioral health services under Medicare and Medicaid

Bryan Hull, Washington Counsel, Division of Legislative Counsel, American Medical Association
Sidney Welch, Bradley Arant Boult Cummings LLP

• An overview of the final Medicare Physician Fee Schedule for 2025
• Implications of the changes contained in the final MPFS
• Trending topics in the MPFS
• Other new developments and operational realities of physician payment
• Where should we expect in 2026

Emily J. Cook, McDermott Will & Emery LLP
Jeff I. Davis, Bass, Berry & Sims

• The laws and regulations outside of the 340B Statute that 340B Covered Entities need to understand
• Example scenarios of arrangements requiring review under the 340B Statute and other federal and state laws will be presented and analyzed
• Applicable requirements and penalties for violation
• Examples of the following arrangements, among others: Alternative distribution, provider-based rules, management agreements, and medication therapy management models

Margia K. Corner, Sheppard Mullin

• Session description to follow

Charles A. Luband, Dentons

Medicaid is a program jointly financed by the federal government and the states. The financing rules that specify how the federal government will and will not match the non-federal share is a case study in federalism and has shaped the Medicaid program’s structure. This session focuses on Medicaid financing issues, including but not limited to the bulleted items below.

• Federal Financial Participation and the Federal Medical Assistance Percentage
• Permissible sources of the non-federal share
• Disputes and ambiguities regarding intergovernmental transfers and provider taxes
• Provider Tax waivers and hold harmless issues

Lisa A. Hathaway, Staff Vice President, Associate General Counsel Centene Corporation
Kathy Roe, Managing Attorney and Co-Founder Health Law Consultancy

In this environment, Medicare Advantage Organizations need to evolve and CMS is making sure MAOs do by demanding ever more from their performance. This session will focus on CMS’s expanding expectations of MAOs by addressing:

• Quality—evidenced by evolving measures and measurement for the Star Ratings program
• Benefits with value—manifested by enhanced requirements for supplemental benefits
• Utilization management practices—demonstrated by new interoperable FHIR-based APIs, annual health equity analysis mandates and use of artificial intelligence by MAOs
• Updates for supplemental benefits, ending of VBID, dual eligible special needs plans and transitions & ending of Medicare-Medicaid Plans, and changes to medical loss ratios

Pam D'Apuzzo, VMG Health
Mitchell Surface, Maynard Nexsen, PC

• Uptick in Providers (MD/QHP) opting out of Medicare and implementing the concierge practice model (i.e., cash only practice)
• Provider options with respect to his/her relationship with Medicare (participating, non-participating, or opt-out Provider)
• What it means to be a Provider (and a patient of a Provider) that has opted out of Medicare
• Common reasons why Providers opt out of Medicare • FAQs related to opting out of Medicare

Daniel J. Hettich, King & Spalding LLP

• Leveraging the perspective and experience of both a private practice Medicare reimbursement litigator and a DOJ litigator, this session will cover:
• The past year’s significant Federal court cases or decisions affecting Medicare reimbursement, including Advocate Christ v Becerra, the Medicare DSH case currently pending before the U.S. Supreme Court
• Issues particularly pertinent to Medicare litigation such as agency deference post-Chevron, jurisdiction, substantive and procedural challenges, and remedies
• What recent decisions and tell us about the strengths and weaknesses of ongoing Medicare reimbursement appeals
• Potential areas of future Medicare litigation implicated by the past year’s developments

Laura Laemmle-Weidenfeld, Jones Day

• Recent developments in CMS’s program integrity efforts
• Recent priorities and developments in HHS-OIG enforcement efforts
• Recent priorities and developments in DOJ civil and criminal enforcement and False Claims Act case law

The Honorable Christopher Randolph, Deputy Chair, HHS Departmental Appeals Board
Deborah Samenow, DLA Piper LLP (US)

• Legal framework/guidance for Medicare Appeals
• Lifecycle of an Appeal
• Update from the Office of Medicare Hearings and Appeals
• Update from the Medicare Appeals Council/DAB
• Case example
• Special Issues–Impact of Loper Bright/Corner Post

Susan Feigin Harris, Norton Rose Fulbright US LLP
Rachel Gilbert, Burr & Forman LLP

• Session description to follow

Roger L. Jansson, CommonSpirit Health
Colin P. McCarthy, Kaufman & Canoles, PC

• Investigation scope, roles and responsibilities – in-house counsel, outside counsel
• Establishing attorney-client privilege
• Interactions with company employees
• Engagement of outside experts and consultants
• Protection of privileged work product
• Closing out the investigation

Kathy Ghiladi, Feldesman Leifer LLP

• What health law practitioners should know about safety net health care providers in the Medicare and Medicaid programs
  • Federally qualified health centers
  • Rural health clinics
  • Safety net hospitals such as critical access hospitals
  • Medicare provider type created by the Consolidated Appropriations Act of 2021, namely, Rural Emergency Hospitals

Kelsey Bagheri, University of California
Christine Johnson, Davis Wright Tremaine

• Background
• Policy debates and financial impacts
• Commercial payer conflicts
• What’s next

James M. Daniel, Hancock, Daniel & Johnson, PC
Chad Mulvany, Forvis Mazars

• The recently finalized CMS Transforming Episode Accountability Model (TEAM)
• Importance of using physician gainsharing to succeed in bundled payment models
• CMS’s/TEAM’s legal requirements for compliant gainsharing arrangements
• Regulatory and legal implications for fraud and abuse laws and interaction with other payment models
• Provide a framework for the data and reporting infrastructure needed to support compliant gainsharing

Lisa Orhin Wilson, Senior Technical Advisor, Centers for Medicare and Medicaid Services
Albert W. Shay, Morgan Lewis & Bockius LLP

• Using hypothetical scenarios, this advanced-level presentation will provide new insight into some of the “basic” concepts fundamental to the physician self-referral law
• Connecting the dots between various pieces of governmental guidance, the speakers will explore topics including remuneration, referrals, the in-office ancillary services exception, and “one-off” issues that can prove challenging to ensuring compliance with the physician self-referral law
• The speakers welcome your questions in advance of the panel, and will do their best to incorporate them into the presentation
• Audience participation is encouraged!

Hope Levy Biehl, Davis Wright Tremaine LLP
Ryan Thurber, Polsinelli PC

• The history and current developments involving the growing trend to shift patient care for acute illnesses into the home
• Efforts at the federal and state level to enable patients to undergo increasingly acute treatment in their home environment, including CMS waiver programs, state accommodations, and areas of opportunity for growth
• Challenges unique to this care model, including:
  • Reimbursement for services delivered in the home
  • Facility and professional licensure considerations
  • Enrollment, credentialing, and participation
  • Coordination of the comprehensive delivery of health care at home across providers
• A look to the future of home-based acute health care services, and what it might mean for patients, new market entrants, and institutional providers over the coming years

Richelle Marting, Marting Law LLC; Director of Managed Care Contracting for North Kansas City Hospital

The 2024 Medicare Advantage plan Final Rule raised a number of hot topics affecting both providers and MA plans from prior authorizations, to the use of internal coverage criteria. This session addresses the detailed nuances of the Final Rule critical for plans, health care organizations, and their counsel to know to effectively operationalize CMS requirements. These detailed nuances include:

• When prior authorizations can be used
• Effect of a prior authorization on coverage and payment
• Evolving issues with prior authorizations and post-claim reviews
• Discussion of circumstances when MA plans can develop internal coverage criteria
• Specific requirements for MA plans' internal coverage criteria
• Trending issues between provider organizations and MA plans surrounding coverage criteria

Jonathan Mason, Moss Adams LLP
Stephanie A. Webster, Ropes & Gray LLP

• The impact of the Medicaid redeterminations on Medicare DSH and 340b qualification
• 1115 waiver District Court decision in Baylor All Saints Medical Center
• The struggles/pitfalls (including common MCReF warnings) with the new cost report templates for Medicare DSH, Worksheet S-10, and Medicare Bad Debt
• Federal UC pool trends and report findings from latest round of nationwide S-10 audits
• Status of other pending litigation on the Medicare DSH payment, including challenges to Part C days in pre-10/1/2013 periods, Advocate Christ Medical Center case on days counted as “entitled” in the SSI fraction, Battle Creek case on whether hospitals can appeal directly from CMS’s published SSI fractions, and litigation on capital DSH
• Bridgeport Hospital decision and its impact on the low wage index policy

Scott Gold, Forvis Mazars
Vacheria T. Keys, Director, Policy & Regulatory Affairs, National Association of Community Health Center

• How Medicare and Medicaid reimburse Rural Health Clinics (RHCs)
• How the Medicare final rules affect both RHCs and FQHCs
• How Medicare and Medicaid reimburse Federally Qualified Health Centers (FQHCs)
• How RHCs are adapting to the new reimbursement rules under the Medicare Modernization Act
• Specific states that are using an alternative payment methodology (APM) to reimburse FQHCs
• How clinics are employing strategies to increase both Medicare & Medicaid reimbursement

Timothy P. Blanchard, Blanchard Manning LLP

• A brief review of the Fundamentals
• Medicare Coverage Policies: NCDs and LCDs
• Claims Processing, Overpayment, and Administrative Sanction Risks
• Medicare Advantage Issues
• False Claims and Health Care Fraud Implications

Bradley Cunningham, Lead Policy and Regulatory Analyst, Association of American Medical Colleges
Andrew D. Ruskin, K&L Gates LLP

• Graduate medical education fundamentals
• Optimizing use of opportunities to expand FTE caps
• Protecting a hospital against establishment of a low per-resident amount
• Proper determination of the available bed count
• Status of litigation in relation to all these reimbursement concepts
• Policy considerations under the new administration

Michelle Webb, Senior Practice Attorney, Ascension
Vivian Wozniak, Vice President & Senior Counsel, Texas Children's Health Plan

With over 74% of the Medicaid population enrolled in comprehensive Medicaid managed care organizations (MCOs), network participation agreements and corresponding business relationships with MCOs are a significant component of managed care operations. This session will discuss issues specific to Medicaid managed care from the payer and provider perspective, including:

• A fundamental understanding of the complex regulatory and financial landscape
• Reimbursement        
• Key Contracting considerations
• Alternative Payment Models and Value Based Arrangements

Margia K. Corner, Sheppard Mullin

• Session description to follow

Michael H. Cook, Liles Parker PLLC
Juliet Charron, Deputy Director, Medicaid & Behavioral Health, Office of the Director | Idaho Department of Health and Welfare
Jay Ludlam, Deputy Director for Medicaid, North Carolina Department of Health and Human Services
Cheryl J. Roberts, Director, Virginia Department of Medical Assistance Services

• How the Medicaid program is changing in a particular state and nationally
• Innovative features of the particular State's Medicaid program potentially addressing such items as social determinants of health care (SODH), health equity, managed care organizations, the opioid crisis, the fallout from the Medicaid winddown, behavioral health, expansion, APMs, long term care and home and community-based care, and 1332 and 1115 waivers
• If and how public health issues such as COVID is still affecting their various programs, e.g. staffing shortages, and potentially what lessons have they learned and the actions the state is taking to prepare for future pandemics

Julie Burns, Office of the General Counsel, US Department of Health and Human Services
Judith A. Waltz, Foley & Lardner LLP

• Session description to follow

Zubin Khambatta, Holland & Knight
Praveen Mekala, Assistant Vice President, Networ Finance, WMCHealth Network
K. Michael Nichols, University of Illinois Hospital and Clinics

IPPS recently celebrated its 40th birthday. Is the current methodology working to meet the needs of Medicare, Medicaid and other payers, and most importantly the hospital provider community? This program will combine the perspectives of seasoned hospital financial professionals and an attorney with extensive experience in payment policy focusing on Medicaid payment issues. Our objectives include:

• Understanding of the current inputs used in Medicare PPS rate developments
• How structural changes within the hospital industry may not be reflected in the current rate setting methodology
• How COVID has permanently changed the health care environment
• The relevance of using Medicare rates for Medicaid and other payers
• How various special payment adjustments may distort the rate base

Marc Hartstein, Principal, Health Policy Alternatives, Inc.
Katrina Pagonis, Hooper, Lundy & Bookman PC

• Inpatient hospital payment update
• Wage index issues
• Disproportionate share and uncompensated care payments
• Transforming Episode Accountability Model (TEAM) demonstration
• New technology add-on payment changes

Daniel J. Hettich, King & Spalding LLP

• Leveraging the perspective and experience of both a private practice Medicare reimbursement litigator and a DOJ litigator, this session will cover:
• The past year’s significant Federal court cases or decisions affecting Medicare reimbursement, including Advocate Christ v Becerra, the Medicare DSH case currently pending before the U.S. Supreme Court
• Issues particularly pertinent to Medicare litigation such as agency deference post-Chevron, jurisdiction, substantive and procedural challenges, and remedies
• What recent decisions and tell us about the strengths and weaknesses of ongoing Medicare reimbursement appeals
• Potential areas of future Medicare litigation implicated by the past year’s developments

Patrick Brennan, Manatt Phelps & Phillips LLP
Kristie C. Gurley, Covington & Burling LLP
Natalie Mazina, Mazina Law

On August 16, 2022, President Biden signed into law the Inflation Reduction Act of 2022 (IRA)—the law’s “Prescription Drug Pricing Reform” provisions represent the most significant changes to Medicare payment for drugs and biologicals in decades

• Among other provisions, the law authorizes the Medicare program to negotiate prices for certain Medicare-covered drugs, and requires manufacturers that raise their drug prices faster than the rate of inflation to pay a rebate to Medicare and reduces Part B coinsurance for these drugs for people with Medicare
• The law also contains several other provisions intended to reduce out-of-pocket expenditures for Medicare beneficiaries for drugs and certain vaccines
  • CMS’ ongoing implementation of the IRA’s Prescription Drug Pricing Reform provisions for initial price applicability year (IPAY) 2026 and beyond
  • The key statutory provisions, timelines, and the steps CMS has taken to implement them to date, with a primary focus on the drug price negotiation provisions
  • Legal considerations for pharmaceutical companies, pharmacies, and providers as a result of the changes under the IRA, and how those changes will affect patients in the coming years

Christine Blowers, Director, Division of Systems & Case Management, Office of Hearings, CMS
Leslie Demaree Goldsmith, Bass Berry & Sims
Lisa Ogilvie-Barr, Director, Division of Hearings & Decisions, Office of Hearings, CMS

• OH CDMS overview and updates
• Jurisdictional, procedural, and case management concerns
• Avoiding pitfalls and applying best practices before the Board
• Emerging trends

Bryan Hull, Washington Counsel, Division of Legislative Counsel, American Medical Association
Sidney Welch, Bradley Arant Boult Cummings LLP

• An overview of the final Medicare Physician Fee Schedule for 2025
• Implications of the changes contained in the final MPFS
• Trending topics in the MPFS
• Other new developments and operational realities of physician payment
• Where should we expect in 2026

Emily J. Cook, McDermott Will & Emery LLP
Jeff I. Davis, Bass, Berry & Sims

• The laws and regulations outside of the 340B Statute that 340B Covered Entities need to understand
• Example scenarios of arrangements requiring review under the 340B Statute and other federal and state laws will be presented and analyzed
• Applicable requirements and penalties for violation
• Examples of the following arrangements, among others: Alternative distribution, provider-based rules, management agreements, and medication therapy management models

Jeanne L. Vance, Weintraub Tobin

• What is CMMI, what do they do and why?
• What are the current CMMI models being tested?
• How are the models selected?
• What factors should providers consider when deciding whether to participate in voluntary CMMI models?
• Mandatory models and provider issues.

Susan Banks, Holland & Knight, LLP
B. Scott McBride, Morgan, Lewis & Bockius LLP

• Analyze the January 2025 Overpayments Final Rule and CMS’s new definition of “identified”
• Consider what’s left of judicial deference in the wake of Loper Bright and what this all means (and doesn’t) for providers navigating potential overpayment situations
• Discuss several compliance and overpayment scenarios to assess likely conditions of payment, explore the role of subregulatory guidance, evaluate available deference and rulemaking related defenses, and consider implications for scienter arguments
• Distill practical takeaways for providers conducting internal investigations and defending false claims allegations

Pam D'Apuzzo, VMG Health
Mitchell Surface, Maynard Nexsen, PC

• Uptick in Providers (MD/QHP) opting out of Medicare and implementing the concierge practice model (i.e., cash only practice)
• Provider options with respect to his/her relationship with Medicare (participating, non-participating, or opt-out Provider)
• What it means to be a Provider (and a patient of a Provider) that has opted out of Medicare
• Common reasons why Providers opt out of Medicare • FAQs related to opting out of Medicare

Zubin Khambatta, Holland & Knight
Praveen Mekala, Assistant Vice President, Networ Finance, WMCHealth Network
K. Michael Nichols, University of Illinois Hospital and Clinics

IPPS recently celebrated its 40th birthday. Is the current methodology working to meet the needs of Medicare, Medicaid and other payers, and most importantly the hospital provider community? This program will combine the perspectives of seasoned hospital financial professionals and an attorney with extensive experience in payment policy focusing on Medicaid payment issues. Our objectives include:

• Understanding of the current inputs used in Medicare PPS rate developments
• How structural changes within the hospital industry may not be reflected in the current rate setting methodology
• How COVID has permanently changed the health care environment
• The relevance of using Medicare rates for Medicaid and other payers
• How various special payment adjustments may distort the rate base

Roger L. Jansson, CommonSpirit Health
Colin P. McCarthy, Kaufman & Canoles, PC

• Investigation scope, roles and responsibilities – in-house counsel, outside counsel
• Establishing attorney-client privilege
• Interactions with company employees
• Engagement of outside experts and consultants
• Protection of privileged work product
• Closing out the investigation

Kathy Ghiladi, Feldesman Leifer LLP

• What health law practitioners should know about safety net health care providers in the Medicare and Medicaid programs
  • Federally qualified health centers
  • Rural health clinics
  • Safety net hospitals such as critical access hospitals
  • Medicare provider type created by the Consolidated Appropriations Act of 2021, namely, Rural Emergency Hospitals

Hope Levy Biehl, Davis Wright Tremaine LLP
Ryan Thurber, Polsinelli PC

• The history and current developments involving the growing trend to shift patient care for acute illnesses into the home
• Efforts at the federal and state level to enable patients to undergo increasingly acute treatment in their home environment, including CMS waiver programs, state accommodations, and areas of opportunity for growth
• Challenges unique to this care model, including:
  • Reimbursement for services delivered in the home
  • Facility and professional licensure considerations
  • Enrollment, credentialing, and participation
  • Coordination of the comprehensive delivery of health care at home across providers
• A look to the future of home-based acute health care services, and what it might mean for patients, new market entrants, and institutional providers over the coming years