Thomas W. Coons

Thomas W. Coons

Ober|Kaler

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Providers Challenge CMS's Non-Hospital Rotation Rules for GME and IME

Prior to the enactment of the Affordable Care Act (ACA), CMS required hospitals to comply with a number of exacting payment and documentation rules in order to include as part of their graduate medical education (GME) and...more

10/20/2014 - Affordable Care Act Healthcare Healthcare Reform Hospitals

District Court Rejects Hospitals' Challenge to CMS's Rebilling Policy

On September 17, the United States District Court for the District of Columbia ruled that it lacked jurisdiction over a challenge brought by the American Hospital Association (AHA) and several hospitals and systems (the...more

10/7/2014 - American Hospital Association Billing CMS Healthcare Hospitals Medicare Part B

CMS Waves Partial White Flag in Appeals of Payment Status Denials

For the last several years, hospitals, on the one hand, and the Centers for Medicare and Medicaid Services and its contractors (collectively, CMS), on the other, have been engaged in a spirited dispute over claims denials for...more

9/8/2014 - Administrative Appeals Claims Procedures CMS Final Rules Hospitals IPPS Medicaid Medicare OMHA

Overview of the FY 2015 IRF Final Rule

On August 6th, the Centers for Medicare and Medicaid (CMS) published an Inpatient Rehabilitation Facility (IRF) final rule [PDF] in the Federal Register outlining (1) new Medicare payment policies and rates; and (2) guidance...more

8/22/2014 - CMS Healthcare Inpatient Quality Reporting IRF Claim Processing

CMS Publishes FY 2015 Final IPPS Rule

On August 4, 2014, CMS posted its final changes and updates to the Medicare Inpatient Prospective Payment System (IPPS) that apply for fiscal year (FY) 2015, effective October 1, 2014. Below are some of the highlights of the...more

8/12/2014 - CMS Final Rules Hospitals IPPS Long Term Care Facilities Medicaid Medicare Physician Medicare Reimbursements

OIG Determines $4.3 Million Improperly Paid to LTCHs for Interrupted Stays in 2010 and 2011

The OIG issued a report on June 3, 2014 summarizing its findings concerning the vulnerabilities and enforcement of Medicare’s interrupted-stay policy for long-term care hospitals (LTCHs). Beneficiaries in LTCHs tend to have...more

7/28/2014 - Healthcare Hospitals Long Term Care Facilities Long-Term Care OIG

Medicare's LTCH Moratorium - CMS Issues Instructions and Proposed Regulation

From the early 1980s until the end of the first decade of the 21st century, the number of long-term acute care hospitals (LTCHs) expanded many fold. Addressing this growth, Congress, in enacting the Medicare, Medicaid and...more

6/6/2014 - CHIP CMS Healthcare Healthcare Reform Hospitals Long Term Care Facilities Medicaid Medicare

Changes Proposed to PRRB Dissatisfaction Requirement

On May 15, 2014, CMS published in the Federal Register its FY 2015 IPPS Proposed Rule [PDF], which included changes and updates to its Medicare IPPS policies. 79 Fed. Reg. 27978-28384. One change that CMS proposes is to amend...more

6/5/2014 - Affordable Care Act CMS Hospitals IPPS Jurisdiction Long Term Care Facilities Medicare Proposed Regulation

Proposed 2015 IPPS Rule Contains Many Changes to GME and IME Rules

Each year when CMS publishes its proposed changes to the IPPS Rule, it suggests a number of graduate medical education (GME) and indirect medical education (IME) reforms. This year has been no different. As part of the IPPS...more

5/22/2014 - Affordable Care Act Census CMS GME Healthcare Hospitals IPPS Long Term Care Facilities Medicare Proposed Regulation

CMS Publishes Inpatient Prospective Payment System (IPPS) FY 2015 Proposed Rule

On April 30, 2014, CMS posted its proposed changes and updates to the Medicare IPPS [PDF] that would apply beginning in fiscal year (FY) 2015. Comments are due by June 30, 2014. Below is a summary of the major changes to the...more

5/19/2014 - CMS Healthcare Hospitals IPPS Long Term Care Facilities Medicare Proposed Regulation Provider Payments Public Comment

Highlights of the Protecting Access to Medicare Act of 2014

On the first of this month, President Obama signed into law the Protecting Access to Medicare Act of 2014. The measure extends a multitude of provisions that were set to expire and also incorporates many provisions that may...more

4/28/2014 - Healthcare Healthcare Reform Medicare Protecting Access to Medicare Act

Providers Win Significant Victory in DSH Part C Days Appeal

As we discussed in a Payment Matters article dated December 13, 2012, providers have enjoyed repeated success in challenging the Secretary’s position regarding Medicare Part C days and where those days belong in the Medicare...more

4/25/2014 - DSH Healthcare Medicare Medicare Part C

Providers Lose DSH GA Day Challenge

As we reported in a Payment Matters article dated April 18, 2013, in Nazareth Hosp. et al. v. Sebelius (“Nazareth”), the United States District Court for the Eastern District of Pennsylvania overturned CMS’s rejection of...more

4/24/2014 - DSH Healthcare Hospitals Medicare

"Incident To" Personnel and Credentials: CMS's New Teeth to Address an Old Problem

Medicare’s “incident to” provision found at 42 U.S.C. § 1395x(s)(2)(A) addresses coverage of services and supplies furnished “incident to a physician’s professional service,” principally in a physician’s office or clinic....more

1/24/2014 - CMS Compliance Healthcare Hospitals IPPS Medicare

SGR-Driven Payment Reduction Postponed Again

As part of the Balanced Budget Act of 1997 (BBA), Congress enacted a number of payment reforms designed to curb the growth of expenditures under Medicare Part B. One of the more notable of those provisions was the Sustainable...more

1/8/2014 - CMS Healthcare Healthcare Professionals Medicare Medicare Part B Physician SGR Formula Physicians

CMS Announces New Cost Reporting Procedures to Address DSH Uncompensated Care Payments

In the fiscal year 2014 Inpatient Prospective Payment System (IPPS) rule (the “final rule”), CMS explained the new disproportionate share hospital (DSH) payment methodology that took effect this October 1. As we reported in...more

10/18/2013 - CMS DSH Hospitals Patient Prospective Payment System

IPPS Final Rule: CMS Addresses Allina Decision and Addresses New Medicare DSH Payment Calculations

In the fiscal year 2014 Inpatient Prospective Payment System (IPPS) rule published in the Federal Register on August 19, 2013, CMS took two steps of note regarding the Medicare disproportionate share hospital (DSH)...more

8/28/2013 - CMS Disproportionate Share Adjustments Healthcare Hospitals Medical Expenses Medicare Payment Plans

Medicare Bad Debts and CMS's "At a Collection Agency Policy" - New Uncertainty

As reported in previous Payment Matters articles (6/11/08, 4/4/13 and 6/27/13), the United States District Court for the District of Columbia has ruled in two separate opinions that a Medicare contractor is not permitted to...more

8/12/2013 - Bad Debt CMS Collection Agencies Debt Medical Expenses Medicare

CMS's Use of Contractors to Determine "Sustained or High Level of Payment Errors" Upheld

In a decision handed down on July 23, 2013, the United States Court of Appeals for the D.C. Circuit upheld the use by CMS of outside contractors to determine whether a home health agency’s reimbursement claims had exhibited a...more

8/9/2013 - CMS Contractors Healthcare Home Health Care Medicare Overpayment Reimbursements

CMS Proposes Significant Changes and Clarifications in OPPS Proposed Rule

In its OPPS proposed rule published July 19, 2013 [PDF], at Fed. Reg. 43534-43707, CMS proposed significant changes and clarifications to its current policy. Among the most notable changes are the four discussed below...more

7/24/2013 - CMS Healthcare Hospitals Medicaid Medicare Physicians

Court of Appeals Hands Down Significant DSH Ruling

As we reported in a Payment Matters article dated February 16, 2012, early last year the United States District Court for the District of Columbia handed providers a significant victory in Catholic Health Initiatives-Iowa v....more

6/28/2013 - CMS DSH Healthcare Medicaid Medicare

CMS Prevails in DSH Challenge Involving Waiver-Expansion Days

Over the years, CMS and its contractors have wrestled with how days approved under a Medicaid demonstration project should be counted, if at all, for purposes of the Medicare disproportionate share hospital (DSH) calculation....more

5/22/2013 - CMS Deficit Reduction DSH Waivers

Court Grants Unexpected Victory to Providers on Medicare DSH Adjustment

The United States District Court for the Eastern District of Pennsylvania’s opinion in Nazareth Hosp. v. Sebelius, slip op. no. 10-3513 furnished a surprising victory to two providers that challenged the calculation of the...more

4/18/2013 - CMS DSH Medicaid Medicare Patients

Court of Appeals Rules for Government in DSH Exhausted Benefit Day Appeal

For the last several years, hospitals and the government have fought hard over where days associated with certain “dual eligible” patients should be placed in the Medicare disproportionate share hospital (DSH) calculation. At...more

4/5/2013 - DSH Health Insurance Medicaid Medical Reimbursement Medicare Medicare Advantage

Court Places Limits on Secretary's "No Reopening" Arguments

CMS has often argued that “base year” determinations cannot be revisited once the three-year reopening period has closed. Now, a recent decision from the U.S. Court of Appeals for the District of Columbia Circuit places those...more

3/31/2013 - CMS FTEs Hospitals Kaiser v Sebelius Reimbursements

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