Leslie Demaree Goldsmith

Leslie Demaree Goldsmith

Ober|Kaler

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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

Uncertainty Continues for Two-Midnight Rule's Payment Reduction

In Shands Jacksonville v. Burwell [PDF], No. CV 14-1477, 2015 WL 5579653, (D.D.C. Sept. 21, 2015), the United States District Court for the District of Columbia gave the Secretary of the Department of Health and Human...more

10/14/2015 - Administrative Procedure Act HHS Hospitals Inpatient Billing Medicare Notice and Comment Provider Payments Rulemaking Process Secretary of HHS Two-Midnight Rule

Court Upholds CMS Treatment of Multi-Campus Hospitals as Single Entities for Wage Index Purposes

The United States Court of Appeals for the District of Columbia recently upheld the decision of the Secretary of Health and Human Services (Secretary) that a multi-campus hospital straddling two geographic areas should be...more

9/19/2015 - CMS Hospitals Single Entity Rule Wage Index

Home Health, CY 2016 Proposed Rule: Emphasis on Value-Based Purchasing

On July 10, 2015, CMS published the calendar year (CY) 2016 home health prospective payment system (PPS) proposed rule [PDF]. While the proposed rule updates and revises certain payment rates and quality measures, it also...more

8/25/2015 - Affordable Care Act CMS Home Health Care IMPACT Act Inpatient Quality Reporting Medicare OASIS Patient Prospective Payment System Value-Based Purchasing

CMS Proposes Limited Exception to Two-Midnight Rule and QIO Review of Short Stays

In the 2016 inpatient prospective payment system (IPPS) proposed rule, CMS promised to provide further guidance on the controversial "two midnight" rule in the forthcoming outpatient prospective payment system (OPPS) rule....more

7/31/2015 - CMS Exceptions Inpatient Prospective Payment System (IPPS) MACs QIOs Two-Midnight Rule

CMS Issues CY 2016 Proposed Rule for OPPS, ASC Payment Systems and Quality Reporting

On July 8, 2015, CMS published in the Federal Register [PDF] its proposed changes and updates to the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy...more

7/30/2015 - CMS Health Care Providers Healthcare Hospitals OPPS Patient Prospective Payment System Proposed Regulation Two-Midnight Rule

CMS Pays $1.3 Billion to Hospitals for Settlements of Medicare Inpatient Appeals

On June 11, 2015, CMS announced that it had entered into settlements with over 1,900 hospitals for over 300,000 disputed inpatient billing claims. CMS updated its website dedicated to inpatient hospital reviews, noting that...more

6/27/2015 - CMS Healthcare Hospitals Inpatient Billing Medicare Settlement Agreements

CMS Issues DSH Ruling 1498-R2

CMS recently issued Ruling 1498-R2 (Ruling), dated April 22, 2015, amending its 2010 Ruling 1498-R. The new Ruling addresses the calculation of the Medicare fraction of the disproportionate share hospital (DSH) adjustment for...more

5/5/2015 - CMS DSH Adjustments MACs Medicare Medicare Part A PRRB

"Next Generation" ACO Model Announced by CMS

In a March 10, 2015 press release, CMS announced a new addition to its existing Accountable Care Model (ACO) portfolio: Next Generation ACOs. As stated by CMS in its press release, this new ACO model will allow for already...more

4/9/2015 - ACOs Affordable Care Act CMS HHS Next Generation ACO (NGACO)

Beginning April 1, HHA Payment Will Be Determined By CMS Generated Code Using OASIS Data

Payment for a particular home health agency (HHA) beneficiary’s episode of care is based on a Health Insurance Prospective Payment System (HIPPS) code. There are three sources for the HIPPS code and they do not always agree:...more

3/5/2015

CMS Proposes Changes to the Medicare Shared Savings Program MSSP

On December 1, 2014, CMS published its proposed changes and updates to the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs). Comments are due by February 6, 2015. Below is a summary of the...more

1/9/2015 - ACOs CMS Healthcare Medicare Medicare Shared Savings Program Proposed Amendments

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