Thomas W. Coons

Thomas W. Coons

Ober|Kaler

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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

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

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

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

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

CMS Revises Part B Billing Policy for Unnecessary Inpatient Admissions

For many years, CMS policy has been that, if an inpatient admission was denied for medical necessity reasons, the hospital could bill under Part B for only a limited set of services that, significantly, did not include...more

3/29/2013 - Administrative Appeals ALJ CMS Hospitals Medicare Medicare Part B

Supreme Court: Providers' Appeal Period Not Extended by Doctrine of Equitable Tolling

Under the Medicare statute and implementing regulation, providers have 180 days from the issuance of a Notice of Program Reimbursement (NPR) in which to file an appeal to the Provider Reimbursement Review Board (PRRB). This...more

2/7/2013 - Appeals Equitable Tolling Medicare NPR Provider Reimbursement Review Board

Court Rules That Medicare DSH Statute Means What It Says

In recent times, the provider community has enjoyed success in challenging the Secretary’s interpretation of the Medicare disproportionate share hospital (DSH) adjustment provisions and what, the providers have maintained,...more

1/25/2013 - Appeals Disproportionate Share Adjustments Hospitals Medicare Retroactive Application

Extension of Time for Overpayment Recoveries in Fiscal Cliff Law Not as Broad as it Sounds

The recently passed fiscal cliff legislation, i.e., the American Taxpayer Relief Act of 2012 (Act) [PDF], includes a number of provisions addressing Medicare and Medicaid. One of these provisions extends the recovery period...more

1/18/2013 - American Taxpayer Relief Act CMS Extensions Fiscal Cliff Medicaid Medicare OIG Overpayment Recovery Laws Reopening Laws Social Security Act

Providers Again Win in Medicare Disproportionate Share Adjustment Challenge

In a 2011 decision, Northeast Hospital Corp. v. Sebelius, 657 F. 3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit ruled for the providers in a challenge to the Secretary’s...more

12/13/2012 - Appeals Disproportionate Share Adjustments Medicare

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