Thomas W. Coons

Thomas W. Coons

Ober|Kaler

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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

D.C. District Court Resolves Challenge to Medicare's Outlier Payment Rules for Banner Health v. Burwell

On March 31, 2016, Judge Colleen Kollar-Kotelly of the United States District Court for the District of Columbia (the “D.C. District Court”) issued a highly anticipated memorandum opinion settling what will probably be the...more

5/13/2016 - Banner Health System HHS Hospitals Medicare Outlier Payments Summary Judgment

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

HHS Psychiatric Hospital Reimbursement Methodology Upheld

On December 29, 2015 the U.S. Court of Appeals for the District of Columbia rejected a challenge to a psychiatric hospital's pre-PPS Medicare reimbursement. Washington Regional Medicorp v. Burwell, No. 1:13-cv-00622 (D.C....more

1/22/2016 - Appeals Chevron Deference HHS Patient Prospective Payment System Physician Medicare Reimbursements Psychiatric Hospitals Split of Authority TEFRA

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

Challenges to Medicare's Outlier Payment Rules - the Secretary Largely Prevails

As we reported in an earlier Payment Matters article, the United States Court of Appeals for the District of Columbia Circuit handed hospitals a partial victory on May 19, 2015, in their challenge to Medicare outlier payments...more

10/30/2015 - Appeals Arbitrary and Capricious Banner Health System Hospitals Medicare Outlier Payment Rules Regulatory Standards Rulemaking Process Secretary of HHS

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

Partial Victory for Hospitals in Medicare Outlier Challenge

In a decision issued May 19, 2015, the United States Court of Appeals for District of Columbia Circuit handed hospitals a partial victory in their challenge to their Medicare outlier payments for 2004. District Hospital...more

6/1/2015 - HHS Hospitals Inpatient Prospective Payment System (IPPS) Medicare Outlier Payments Secretary of HHS

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

HHS Identifies Specific Goals to Move Toward Paying for Quality of Care

On January 26, 2015, the U.S. Department of Health and Human Services (HHS) announced a new initiative to shift Medicare reimbursements from volume to value using new payment methodologies for physicians and hospitals. Such a...more

2/9/2015 - Fee-for-Service Healthcare HHS Hospitals Medicare Physician Medicare Reimbursements Quality of Care Standards

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

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 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

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