News & Analysis as of

OMHA Announces Two New Programs to Address Appeals Backlog

The Office of Medicare Hearings and Appeals (OMHA), which oversees the Administrative Law Judge (ALJ) level of appeal, recently posted two important announcements regarding a new Statistical Sampling Initiative (SSI) and...more

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

Annual Report Shows Meteoric Rise in RAC Activity

On February 5, 2013, CMS issued its mandatory Recovery Audit Contractor (RAC or Recovery Auditor) program annual report, detailing overpayments, underpayments, RAC performance and savings to the Medicare program. According to...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

ALJ Appeals Frequently Favorable To Providers; OIG Calls For Reforms

The OIG recently published a report reviewing the implementation of 2005 regulations regarding the administrative law judge (ALJ) level of appeals, the third level of the Medicare appeals system. The 2005 regulatory changes...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

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