Leslie Demaree Goldsmith

Leslie Demaree Goldsmith

Ober|Kaler

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CMS Releases the 2016 OPPS Final Rule

On November 1, 2016, CMS published its final policy changes, quality provisions, and payment rates for 2017, as they relate to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center...more

11/16/2016 - Affordable Care Act Ambulatory Surgery Centers Bipartisan Budget Act CEHRT CMS EHR Electronic Health Record Incentives Final Rules Hospitals Inpatient Quality Reporting Meaningful Use OPPS Provider Payments Value-Based Purchasing

Home Health Agency PPS Update for 2017: Quality, Quality, Quality

On November 3rd, CMS published the Final Prospective Payment System (PPS) Rule for Home Health Agencies (HHAs) for CY 2017 at 81 FR 76702 (Nov. 3, 2016). The rule implements annual changes to the PPS rate for HHAs and...more

11/15/2016 - CMS Federal Pilot Programs Final Rules Home Health Agencies IMPACT Act Medicare Outlier Payments Outpatient Quality Reporting Prospective Payment System (PPS) Value-Based Purchasing

Court Rules in Favor of Hospitals in Bad Debt Collection Effort

On July 25, 2016, the United States District Court for the District of Columbia issued an opinion favoring provider flexibility in the reasonable collection of Medicare bad debt. Winder HMA, LLC, et al. v. Sylvia Burwell. The...more

10/4/2016 - Administrative Proceedings Appeals Bad Debt Business Judgment Rule Debt Collection HHS Hospitals Medicare Moratorium Provider Payments Provider Reimbursement Manual Provider Reimbursement Review Board PRRB Reversal Secretary of HHS

Court Upholds CMS's Inclusion of Part C Days in Medicare Fraction of DSH Calculation FYE 2012

On August 17, 2016, the United States District Court for the District of Columbia upheld the position of the Secretary of Health and Human Services (Secretary) that Part C patients were to be considered as “entitled to...more

10/3/2016 - Administrative Interpretation Administrative Procedure Act Disproportionate Share Adjustments HHS Hospitals Medicare Medicare Part A Medicare Part C Notice and Comment Provider Payments Remand Summary Judgment Vacated

D.C. District Court Strikes Down PRRB's Application of "Self-Disallowance" Jurisdictional

In Banner Heart Hospital, et al. v. Burwell, the United States District Court for the District of Columbia (Court) held on August 19, 2016, that the Provider Reimbursement Review Board (PRRB) incorrectly declined to hear an...more

10/1/2016 - Appeals CMS Judicial Review Jurisdiction MACs Medicare Outlier Payments Provider Payments PRRB Remand Self-Disallowance

The MOON Notification is Coming: CMS Publishes Final Changes

CMS is moving forward with implementing the Medicare Outpatient Observation Notice (MOON) as announced in its FY 2017 IPPS Final Rule [PDF] on August 2, 2016, and published in the Federal Register on August 22, 2016 (Final...more

9/21/2016 - Beneficiaries CMS Final Rules Hospitals Medicare Medicare Advantage Medicare Outpatient Observation Notice (MOON) Medicare Part A Medicare Part B NOTICE Act OMB Provider Payments

D.C. District Ct Applies Prohibition on Administrative and Judicial Review to IRF PPS Rates

On July 25, 2016, Judge John D. Bates of the United States District Court for the District of Columbia issued a memorandum opinion broadly construing 42 U.S.C. § 1395ww(j) to prohibit administrative or judicial review of a...more

9/16/2016 - Administrative Appeals Appeals CMS Health Care Providers Hospitals Inpatient Rehab Facilities IRF Claim Processing Judicial Review MACs Medicare Payment Rates Provider Payments Provider Reimbursement Review Board

CMS Releases the 2017 IPPS and LTCH PPS Final Rule, Including MOON Requirements

On August 2, 2016, CMS issued its final rule addressing new payment rates and policies under both the Hospital Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System...more

8/26/2016 - CMS Hospitals Inpatient Prospective Payment System (IPPS) Inpatient Quality Reporting Long Term Care Facilities Medicare Medicare Outpatient Observation Notice (MOON) NOTICE Act Provider Payments

Final FY 2017 Inpatient Psychiatric Facilities Payment and Policies Rule, Payment Matters

On August 1, 2016, CMS published the FY 2017 Inpatient Psychiatric Facilities (IPF) Prospective Payment System (PPS) – Rate Update notice. Some of the key changes are highlighted below....more

8/22/2016 - CBSA CMS Inpatient Prospective Payment System (IPPS) OMB Psychiatric Hospitals Wage Index

CMS Releases the 2016 OPPS Proposed Rule

On July 15, CMS published its proposed policy changes, quality provisions, and payment rates for 2017 as they relate to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC)...more

7/25/2016 - Ambulatory Surgery Centers CMS EHR Electronic Health Record Incentives OPPS Proposed Rules Value-Based Purchasing

Home Health PPS CY 2017 Proposed Rule: Payments Rebased, Quality Measures Updated

Downward adjustments to home health episode payments arising from rebasing of the national payment rates, case mix adjustments, and an increase to the fixed dollar loss ratio for calculating outliers will result in an overall...more

7/12/2016 - Affordable Care Act CMS Home Health Care Proposed Rules Provider Payments Public Comment Quality of Care Standards Value-Based Purchasing

Medicare Appeals Backlog: HHS' Response to the Decade-Long Delay in Reviewing Appeals

The Department of Health and Human Services (HHS) published its proposed rule [PDF] revamping the Medicare appeals process at the Administrative Law Judge (ALJ) level on July 5, 2016. The proposed rule extensively revises...more

7/11/2016 - ALJ CMS HHS Medicare Medicare Appeals Council Medicare Claims Appeals Process OMHA

CMS Announces "Pause" in QIO Review of Inpatient Admissions

Last week CMS announced a temporary "pause" in the review of inpatient admissions by the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs). CMS posted this announcement on its Inpatient Hospital...more

6/13/2016 - Administrative Appeals CMS Hospitals Inpatient Quality Reporting QIOs Two-Midnight Rule

CMS Limits MAC and QIC Scope of Review

Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) should not expand redeterminations and reconsiderations of claims denied on the basis of complex pre–or post–pay payments or automated...more

6/10/2016 - Administrative Appeals CMS MACs Provider Payments QICs

CMS's Proposed IPPS and LTCH FY 2017 Rule: Key Takeaways

On April 18, 2016, CMS released its proposed rule addressing new payment rates and policies under both the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS),...more

4/29/2016 - CMS Hospitals Inpatient Prospective Payment System (IPPS) Long Term Care Facilities Medicare Patient Prospective Payment System Proposed Regulation Provider Payments

Medicare Appeals 10-Year Backlog: D.C. Circuit Signals Enough is Enough

Issued within a month of one another, two cases regarding the Medicare appeals backlog reached opposite conclusions, providing a circuit-split. The first case from the D.C. Circuit, signaling a major shift toward judicial...more

4/1/2016 - Administrative Appeals Judicial Intervention Mandamus Petitions Medicare Split of Authority

Court Allows 'Retroactive' Application of 2005 Wage Index Rule Limiting Reimbursement for Pension Plan Costs

On February 22, 2016, in Regents of the University of California v. Burwell, the U.S. District Court for the District of Columbia granted summary judgment in favor of the Secretary of Health and Human Services (the Secretary)...more

3/21/2016 - Administrative Procedure Act Appeals GAAP HHS Hospitals Medicare Notice and Comment Pensions Provider Payments PRRB Retroactive Application Wage Index

Wage Index Reclassification Rule Struck Down by Second Circuit

On February 4, 2016, the United States Court of Appeals for the Second Circuit decided Lawrence + Memorial Hospital v. Burwell. The case addressed a regulation, issued by the Secretary of Health and Human Services...more

3/2/2016 - Chevron Deference Drug Pricing HHS Hospitals Medicare Reclassification Rules Rural Health Care Providers Wage Index

Senate Considering Bill to Speed Medicare Claims Appeals

In early December of last year, Orrin Hatch (Senate Finance Committee Chairman, R-UT) and Ron Wyden (D-OR) introduced the Audit and Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 (AFFIRM Act). The purpose of...more

2/5/2016 - Health Care Providers Medicare Claims Appeals Process Petitions for Review Proposed Legislation Recovery Audit Contractors (RACs) Senate Finance Committee Statistical Sampling

2-Midnight Rule Updates

- CMS Adopts Change to Benchmark and Shift in Enforcement - CMS Explains Reasoning Behind 0.2% Payment Reduction CMS has published discussions of the 2-midnight rule in two recent Federal Register publications. In the...more

1/11/2016 - Benchmarks CMS Inpatient Prospective Payment System (IPPS) Medicare Part A OPPS Provider Payments Two-Midnight Rule

CMS Issues CY 2016 HHA PPS, Value-Based Purchasing and Quality Reporting Final Rule

On November 5th, CMS published the Final PPS Rule for Home Health Agencies (HHAs) for CY 2016. The rule implements annual changes to the PPS rates for HHAs and represents the third year in a four-year rebasing of the rates....more

12/17/2015 - CMS Home Health Agencies IMPACT Act Patient Prospective Payment System Quality Assurance Programs Value-Based Purchasing

CMS Proposes Significant Revisions to Hospital Discharge Planning Process: How Patient Choice May be Impacted

On November 3, 2015, CMS released a proposed rule revising existing discharge planning requirements for hospitals, critical access hospitals (CAHs) and home health agencies (HHA). CMS stated impetus for doing so is to both...more

11/13/2015 - CMS Home Health Care Hospitals IMPACT Act Patient Discharge Planning

Court Upholds HHA Face-to-Face Narrative Requirement

The Medicare statute requires that home health agency (HHA) patients must be homebound and in need of skilled nursing or therapy services in order to receive Medicare HHA services. 42 U.S.C. § 1395f(a)(2)(C). Historically,...more

11/12/2015 - Affordable Care Act Chevron Deference Face-to-Face Narrative Requirement Home Health Care Medicare

The Bad Debt Moratorium Requires a Flexible Approach to Evaluating "Reasonable Collection Efforts"

On September 10, 2015, District Judge Randolph D. Moss of the U.S. District Court for the District of Columbia issued an opinion in Mountain States Health Alliance v. Burwell (Mountain States) involving Section 310 of the...more

10/28/2015 - Administrative Procedure Act Audits Bad Debt Collection Agencies HHS Medicare Moratorium Provider Reimbursement Manual Provider Reimbursement Review Board Reasonable Collection Efforts Repeal Secretary of HHS

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