Thomas W. Coons

Thomas W. Coons


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D.C. Circuit Precludes Review of DSH Uncompensated Care Data

On July 26, 2016, the United States Court of Appeals for the District of Columbia Circuit decided Fla. Health Sciences Ctr. v. Burwell. In that case, the Court analyzed a statutory bar against judicial review of estimates...more

10/5/2016 - Administrative Procedure Act Administrative Review Appeals CMS Disproportionate Share Adjustments DSH Adjustments HHS Hospitals Judicial Review Medicaid Medicare Non-Appealable Decisions Provider Payments Reviewability Determinations

CMS Lifts Temporary Moratorium on Emergency Ground Ambulance Suppliers but Extends and Expands Other Moratoria

On July 29, 2016, CMS announced that it is lifting a temporary moratorium on Medicare Part B, Medicaid, and Children's Health Insurance Program (CHIP) emergency ambulance suppliers, but extending and expanding similar...more

8/23/2016 - Ambulance Providers CHIP CMS Emergency Response Fraud Abuse and Waste Home Health Agencies Medicaid Medicare Medicare Part B Moratorium

Bankruptcy Courts Lack Subject Matter Jurisdiction Over Medicare Issues, Eleventh Circuit Rules

In a detailed opinion that likely constitutes the last word on the matter, the Eleventh Circuit recently held in Fla. Agency for Health Care Administration v. Bayou Shores SNF, LLC that bankruptcy courts lack jurisdiction...more

7/21/2016 - Appeals Bankruptcy Court CMS Contract Termination Exclusive Jurisdiction Medicare Payor Contracts Social Security Act Subject Matter Jurisdiction

Proposed Provider-Based Changes Pose Significant Problems for Hospitals

As we reported in a Payment Matters article last November 12, 2015, Section 603 of the Bipartisan Budget Act of 2015 changes the payment rules applicable to off-campus, provider-based locations that are new as of November 2,...more

7/13/2016 - Bipartisan Budget Act CMS Hospitals Medicare Off-Campus Departments OPPS Provider Payments

CMS Issues Proposed Medicare Part B Drug Payment Model

On March 11, 2016, CMS published in the Federal Register its proposed new Medicare Part B Drug Payment Model. Comments are due by May 9, 2016. Below are some highlights of the proposed rule....more

3/18/2016 - CMS Medicare Part B Prescription Drug Coverage Prescription Drugs Provider Payments

Outliers: CMS Explains its Reasoning for FY2004 Fixed Loss Threshold Calculation

In accordance with the order issued by the D.C. Circuit in District Hospital Partners, LP v. Burwell and related cases, on January 22, CMS issued an explanation of the methodology it used to calculate the fixed-loss threshold...more

2/4/2016 - Administrative Procedure Act CMS Hospitals Inpatient Prospective Payment System (IPPS) Medicare Outlier Payment Rules Reconciliation

CMS Changes to Cost Report and Appeal Rules Are Now in Effect

As part of the Outpatient Prospective Payment System (OPPS) final rule published in the Federal Register on November 13, 2015, CMS made noteworthy changes to the Medicare cost report and appeal rules. See 80 Fed. Reg. 70298...more

1/8/2016 - Amended Regulation Appeals CMS Medicare OPPS Reporting Requirements

Congress Enacts "Provider-Based" Surprise

Hospitals have long tried to expand their footprints by developing, or in many instances acquiring, physician practices and other medical operations to provide services beyond the immediate vicinity of the hospital’s campus....more

11/17/2015 - Bipartisan Budget CMS HOPPS Hospitals Off-Campus Departments Provider Payments

CMS Prevails in Dual Eligible Bad Debt Challenge

In a decision handed down on August 7, 2015, the United States Court of Appeals for the District of Columbia Circuit upheld the denial of the providers' bad debt claims associated with dual eligible beneficiaries. Grossmont...more

9/5/2015 - Appeals Bad Debt CMS Co-Insurance Payments Deductibles Dual Beneficiaries Filing Deadlines Hospitals Medi-Cal Medicaid Medicare Provider Reimbursement Manual

CMS's "At a Collection Agency" Bad Debt Policy - Confusion Continues

As we reported in previous Payment Matters articles, the United States District Court for the District of Columbia has issued inconsistent opinions regarding Medicare's policy not to allow bad debt when that bad debt is still...more

8/26/2015 - Appeals Bad Debt CMS Collection Agencies Health Care Providers Hospitals Medicare Split of Authority

Key Ingredients of CMS' Proposed Comprehensive Care for Joint Replacement Model

On July 14, 2015, CMS released a proposed rule regarding a new, alternative payment model: the Comprehensive Care for Joint Replacement (CCJR) program. Modeled in large part on the Bundled Payments for Care Improvement (BPCI)...more

8/3/2015 - Alternative Payment Models (APM) BPCI Bundled Payments CCJR CMS Hospitals Medicare

Changes Are Afoot for Quality Measures and Physician Payment Provisions

In the proposed Medicare Physician Fee schedule (PFS) update for 2016, CMS announces a number of new policies, making changes to several of the quality reporting initiatives that are associated with PFS payment, and begins...more

7/21/2015 - Biosimilars CMS EHR Incentive Awards Medicare Medicare Access and CHIP Reauthorization (MACRA) Medicare Part B Medicare Shared Savings Program Physician Fee Schedule PQRS Prescription Drugs Value-Based Fees

Challenge to DSH Adjustment Estimates Barred by Statute

In a decision issued on March 31, the United States District Court for the District of Columbia dismissed a challenge by Florida Health Sciences Center, Inc., also known as Tampa General Hospital, to the calculation of its...more

5/1/2015 - Affordable Care Act CMS DSH DSH Adjustments Hospitals Medicare

Recent Changes to Stark Law's Whole Hospital Exception

The federal physician self-referral law, or Stark Law, provides a number of exceptions to the law's prohibition of physician referrals of designated health services to an entity in which the physician has an ownership or...more

12/19/2014 - Affordable Care Act CMS Healthcare Hospitals Patient Referrals Physician Ownership Physicians Stark Law

Highlights of the 2015 OPPS and ASC Final Rule

On October 31, 2014, CMS published its 2015 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates final rule. This annual rule affects the 4,000...more

11/18/2014 - CMS Final Rules Hospitals OPPS Patient Prospective Payment System

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 Claim Procedures CMS Final Rules Hospitals Inpatient Prospective Payment System (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 Inpatient Prospective Payment System (IPPS) Long Term Care Facilities Medicaid Medicare Physician Medicare Reimbursements

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 Inpatient Prospective Payment System (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 Inpatient Prospective Payment System (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 Inpatient Prospective Payment System (IPPS) Long Term Care Facilities Medicare Proposed Regulation Provider Payments Public Comment

"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 Inpatient Prospective Payment System (IPPS) Medicare

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