Administrative Agency Civil Procedure Health

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Tenth Circuit Rebukes CMS for Applying Wrong Regulations in Overpayment Action

The United States Court of Appeals for the Tenth Circuit shot down CMS’s overpayment recoupment related to physical therapy and skilled nursing services, citing multiple errors in CMS’s appeal briefing and concluding that “an...more

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

Second Circuit Applies Stricter Rules for a Plan Administrator’s Noncompliance with Benefit Claims Regulations

In Depth - On April 12, 2016, the US Court of Appeals for the Second Circuit in Halo v. Yale Health Plan, 2016 WL 1426291 (2d Cir. Apr. 12, 2016), addressed various issues that could arise during a plan administrator’s...more

California Court Rules Medicare Does Not Preempt Hospital Claims Against Payer

On April 27, 2016, a California state court judge in a Complex Litigation department for the County of Los Angeles, ruled in favor of 13 of our hospital clients on an important matter involving substantive and financial...more

Prohibition on Pharmacy Inducements Beyond College of Pharmacists’ Authority

In Sobeys West Inc v. Alberta College of Pharmacists, 2016 ABQB 232, the Alberta Court of Queen’s Bench held that amendments to the College of Pharmacists’ Codes of Ethics and Standards of Practice prohibiting inducements to...more

Capturing Flagg: Fifth Circuit, En Banc, Holds that Failure to Complete Pre-suit Medical Board Review Renders Med Mal Defendants...

We previously wrote about the Fifth Circuit’s panel decision and the defendants’ petition for rehearing en banc in this case. As we reported earlier, the issue is whether a non-diverse defendant is improperly joined by...more

Employee Benefits & Executive Compensation Advisory: The ACA: New Concerns for Employer Plan Sponsors Under the Fair Labor...

The Affordable Care Act (ACA) anti-retaliation provisions have been in effect for several years, but have so far largely gone unnoticed. Now that employees can get financial assistance through the Health Insurance...more

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

Office of Medicare Hearings and Appeals Launches Settlement Conference Facilitation Pilot for Medicare Part A Claims

The HHS Office of Medicare Hearings and Appeals (“OMHA”) recently launched Phase III of the Settlement Conference Facilitation (“SCF”) Pilot to help resolve outstanding Medicare Part A appeals. The SCF program is one of...more

Proposed Enrollment Rule Changes - de Facto Exclusion?

Proposed rules, touted as enhancing the provider enrollment process, would provide CMS with sanction authority that closely parallels the OIG’s exclusion authority. Under the proposed rules, CMS would have expanded bases to...more

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

Fourth Circuit Affirms Hospital Did Not Have A Right to an ALJ Hearing Within 90 Days

On March 7, 2016, the United States Court of Appeals for the Fourth Circuit affirmed the district court’s dismissal of hospital system’s request for a mandamus order directing HHS to provide a hearing before an...more

Also In The News - Health Headlines - March 2016

OMB to Review Medicare Appeals Procedures – The Office of Information and Regulatory Affairs (“OIRA”) within the Office of Management and Budget (“OMB”) is set to review new Medicare appeals process proposed rulemaking. ...more

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

Federal Court finds “Systemic Failure” in Processing of Administrative Appeals for Medicare Reimbursement Claims

A win for efficiency: The AHA suit may force shorter adjudication times for Medicare administrative appeals. In 2014, the American Hospital Association (AHA), along with three hospital systems, filed suit against the U.S....more

Congressional Budget Office Issues Cost Estimate Report on Medicare Appeals Reform Act

On February 16, 2016, the Congressional Budget Office (CBO) issued a cost estimate report on the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 (S. 2368). The purpose of the Act is to address the...more

Court Rules Hospitals Must Exhaust HHS Administrative Appeals Process for Medicare Advantage Out-of-Network Payment Dispute

According to a Georgia federal district court ruling issued on February 11, 2016, a group of hospitals must exhaust their out-of-network Medicare Advantage (MA) payment dispute through the Department of Health and Human...more

HHS May Be Forced to Meet Statutory Deadlines for ALJ Appeals

On February 9, 2016, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit reversed a district court’s dismissal for lack of jurisdiction in the American Hospital Association v. Burwell case. ...more

3 Takeaways from the Recent Ruling on Statistical Extrapolations in CMS Audits

On Jan. 20, 2016, a federal district court in the Western District of Texas affirmed a decision of the Medical Appeals Council (Appeals Council) affirming a CMS contractor’s extrapolation methodology used to assess an...more

A Radical Overhaul? The Third Circuit Analyzes the Federal False Claims Act's Public Disclosure Bar after the Patient Protection...

To dismiss a case based on the public disclosure bar, the defense will have to establish that the allegations of fraud already were exposed in the news media or certain federal sources of information. Pharmaceutical,...more

Blog: ALJ Upholds OCR Enforcement Against Lincare, Inc. of $239,800

A U.S. Department of Health and Human Services (HHS) administrative law judge (ALJ) recently sustained an earlier HHS Office of Civil Rights (OCR) decision to impose a civil money penalty (CMP) of $239,800 against Lincare...more

Latest OCR Enforcement Action: Underbed Storage is Not Appropriate for PHI

Recent enforcement actions by the U.S. Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) have highlighted that, not surprisingly, Covered Entities should not leave medical records in a...more

Historic Moment: Husband Reports Wife’s HIPAA Violation Triggering Six Figure Penalty Against Employer

For the second time in history, the Office for Civil Rights (“OCR”) has imposed a civil monetary penalty (“CMP”) against a covered entity for violations of the Health Insurance and Portability Act (“HIPAA”). Lincare, Inc., a...more

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

Big News for the Home Health Industry: Federal Judge Vacates the DOL's Companionship Services Regulations on Minimum Wage and...

As 2014 wound to a close, the United States District Court for the District of Columbia issued a significant decision impacting third-party agencies that provide in-home care to the elderly and ailing. On December 22, 2014,...more

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