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Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

Resubmission of Hospital Claims

On February 13, CGS Administrators, the Parts A and B Medicare Administrative Contractor for Kentucky and Ohio, relayed instructions to Medicare hospitals paid under the Inpatient Prospective Payment System from the Centers...more

Federal Healthcare Fraud Enforcement Efforts Yield a 790% Return

Last week, the U.S. Department of Health and Human Services (HHS) and the DOJ jointly released a report concluding that, for every dollar spent on healthcare fraud investigations in the last three years, the government...more

No Judicial Review of Contractor’s Finding of a High Payment Error Rate, a Condition for Extrapolation

Before a Medicare contractor can use extrapolation to determine an overpayment amount, the Medicare statute requires that it must make a finding that there is a sustained or high level of payment error or that documented...more

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

OIG: Cardiac Catheterization Arrangement Between Hospital and Physicians Not Subject to Sanctions

On January 7, 2013, HHS OIG published a favorable advisory opinion on a management arrangement between a hospital and a cardiology group related to the provision of certain cardiac catheterization services at the hospital. ...more

What To Do If The Feds Come Knocking At Your Door!

Your employee handbook likely addresses, in great detail, the do's and don'ts of using the internet while at the office, guidance on HIPAA, and even the company's policy on sexual harassment, but does it provide any...more

Health Reform + Related Health Policy News Update - January 16, 2013

In This Issue: - Fiscal Cliff Deal Lengthens Medicare Overpayment Recovery Period - Cutting Medicaid Provider Tax May Shift Costs to States, CRS Finds - MedPAC Finalizes Payment Recommendations, GAO Solicits...more

American Taxpayer Relief Act Amends Overpayment Recovery Time Limits

The ATRA significantly alters provider rights related to overpayment recoupment, refunds, audits and claims appeals. A provision entitled "Removing obstacles to collection of overpayments" increases the statute of limitations...more

Effective January 2013: Ordering- and Referring-Only Providers Must Enroll in Texas Medicaid

Texas Medicaid providers that receive referrals from non-participating physicians or other health care providers need to beaware that beginning January 1, 2013, individual providers who arenot currently enrolled in Texas...more

OIG Approves Gift Cards to Encourage Clinical Visits to Health Center

In Advisory Opinion 12-21, the OIG concluded that a Federally qualified health center’s offer of grocery store gift cards to capitated managed care patients would not constitute grounds for the imposition of sanctions under...more

Privatizing Health Insurance Companies For Anti-Fraud Enforcement

The federal government faces overwhelming challenges in trying to stem the tide of fraud in the health care system. The problem is massive, and even with the increase in resources, and adoption of new tools to fight fraud,...more

Congress Amends the Medicare Secondary Payer Act

On December 31, 2012, Congress sent the Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act (“the Act”) of 2012 to President Barack Obama for signature. The Act had strong bipartisan support, passing in...more

The False Claims Act and Healthcare Providers: Key Results from 2012 and Likely Trends for 2013

From the perspective of False Claims Act (FCA) results, 2012 was a decidedly mixed year for healthcare providers. The bad news was quite bad—increased FCA scrutiny by the Department of Justice (DOJ) led to $3 billion of...more

Fraud: Skilled Nursing Facilities And Nursing Homes

When it comes to healthcare fraud enforcement, the government knows how to target its resources. It is estimated that at least 25 percent of all claims paid by Medicare are improper. The government understands the...more

Navigating the Provider Self-Disclosure Protocol

Providers can voluntarily disclose potential fraud with respect to Federal health care programs — Medicare, Medicaid, and potentially private insurers to the extent Federal or state funds are involved — by following the...more

GAO Recommends Strengthening Medicare Prepayment Edits

On December 10, 2012, the Government Accountability Office (GAO) released a report on the use of prepayment edits in the Medicare program and CMS’ oversight of Medicare Administrative Contractors' (MACs) use of these edits....more

Bolstered By Favorable District Court Decision, King & Spalding Now Forming Group Appeals Contesting Inclusion of Part C Days in...

In a recent decision for which King & Spalding organized the appealing group of hospitals and was co-counsel, the D.C. district court ruled that CMS’s regulation requiring the inclusion of Medicare Part C patient days in the...more

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

Plugging The Leak: Tackling The Problem Of Healthcare Fraud

The Justice Department and the Department of Health and Human Services have made healthcare fraud a number one priority – it is another example of the synergy of politics and enforcement. Congress spends more money on...more

OIG Concludes Improvements Needed at ALJ Level of Review

The OIG issued a report on November 15, 2012 (OEI-02-10-00340) in which it concluded that the administrative law judge (ALJ) level of appeal requires improvements in a number of areas due to (i) apparent substantive...more

Hospitals Win a Case Challenging CMS Policy to Include Part C Days in the SSI Fraction in the Medicare DSH Formula

On November 15, 2012, the United States District Court for the District of Columbia released a 33-page opinion ruling in favor of a group of hospitals that had challenged CMS’s policy of including Medicare Part C patient days...more

Sixth Circuit Overturns $82.6 Million Medicare Fraud Judgment

Based on the recent decision in United States, ex rel. Williams v. Renal Care Group, Inc., medical service providers in the Sixth Circuit that have established separate corporate entities to maximize corporate profits and...more

Government Sanctioned for Destruction of Documents

U.S. district court decision may now allow defendants in False Claims Act cases to obtain sanctions where potentially relevant documents are lost or destroyed due to the government's failure to issue a timely litigation...more

OIG Roundtable on Corporate Integrity Agreements

On October 9, 2012, HHS-OIG released a summary report of its August 7, 2012 roundtable concerning corporate integrity agreements (CIAs). Representatives from 32 companies that have entered into CIAs since 2009 attended the...more

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