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Our firm is seeing an uptick in Medicare demand letters for the recovery of overpayment for skin substitutes, such as WoundFixTM, Biobrane, Dermagraft®, AmnioBand®, or AlloPatch®, used in the treatment of wounds. CMS auditors...more
As an attorney specializing in healthcare reimbursement, I have focused my practice on helping healthcare providers navigate the Center for Medicare and Medicaid (“CMS”) administrative appeal process. I usually get a call...more
On September 10, 2019, the Centers for Medicare and Medicaid Services (CMS) announced new authority to revoke providers’ Medicare enrollment and any corresponding provider agreements or supplier agreements through revisions...more
Continuing to look for ways to reduce the Medicare administrative law judge (ALJ) appeals backlog, CMS has explored enhancing the role of Qualified Independent Contractors (QICs) to resolve disputed claims earlier in the...more
Two United States District Courts in Louisiana and Illinois issued split decisions within two weeks of each other on the dire financial issues facing providers every day under the discretionary “penal recoupment” system the...more
When the Centers for Medicare and Medicaid Services (CMS), through a Medicare contractor, conducts a post-payment audit of a provider’s Medicare reimbursements and determines that the provider may have received an...more
The Centers for Medicare and Medicaid Services (CMS) made a number of recent changes to expand the Settlement Conference Facilitation (SCF) process for providers and suppliers mired in the backlog of appeals at the...more
Medicare providers who have overpayments with pending requests for Administrative Law Judge (ALJ) hearings filed on or before March 31, 2019 may now take advantage of the renewed Settlement Conference Facilitation (SCF)...more
With the introduction of RACs, ZPICs, and UPICs, the administrative process for Medicare payment disputes has resulted in three to five year delays in adjudicating claims while providers are faced with almost certain...more
The HHS Office of the Inspector General (“OIG”) has reported the results of a study assessing service and payment denials by Medicare Advantage Organizations (“MAOs”). The study revealed “widespread and persistent MAO...more
Recent opinions by the Fifth Circuit, the Northern and Southern Districts of Texas, and the District of South Carolina offer hope to providers seeking relief from substantial monetary recoupments during the Medicare appeals...more
In a recent decision, the Northern District of Texas, Dallas Division, granted a health care provider a preliminary injunction to prevent the Centers for Medicare & Medicaid Services ("CMS") from withholding Medicare payments...more
Medicare’s implementation of post-payment review through overly aggressive zone program integrity contractors (ZPICs) and unified program integrity contracts (UPICs), combined with an ineffective review process at the first...more
Providers and suppliers who have been assessed overpayments for Medicare services are entitled, by statute, to a stay of recoupment while the provider or supplier’s appeal is pending – but only at the first two levels of...more
A home health agency has scored a second win in its fight to prevent CMS from withholding Medicare payments (to effectuate a recoupment of alleged overpayments), at least for the time being. We previously reported on the...more
The Department of Health and Human Services (HHS) announced on November 3, 2017 additional settlement options for providers and suppliers in an effort to improve the Medicare claims appeals process, which included (1) the Low...more
In an effort to resolve its backlog of Medicare appeals, the Department of Health & Human Services’ Office of Medicare Hearings and Appeals (OMHA) established a Settlement Conference Facilitation (SCF) pilot program in June...more
HHS’s Office of Medicare Hearings and Appeals (OMHA) has long faced a backlog in Medicare appeals to Administrative Law Judges (ALJs). In an effort to address this backlog, OMHA established a Settlement Conference...more
In preparation for the upcoming expansion of its Settlement Conference Facilitation (SCF) program, the Office of Medicare Hearings and Appeals (OMHA) has directed interested providers and suppliers to review the SCF Expansion...more
In January 2018, Centers for Medicare & Medicaid Services (CMS) announced additional information regarding a new Low Volume Appeals (LVA) settlement option and an expanded Settlement Conference Facilitation (SCF) as part of...more
On October 13, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a CMS Transmittal to update the Medicare Program Integrity Manual (MPIM) on recent regulatory changes in the Office of Medicare Hearings and...more
On October 13, 2017, HHS issued a transmittal change request to update Section 3.9 of the Medicare Program Integrity Manual (MPIM), stating that only one entity (CMS or a CMS contractor) may attend an ALJ hearing as a party,...more
The U.S. Department of Health and Human Services (HHS) released a Final Rule aimed at reducing and eventually eliminating the backlog of more than 650,000 claims currently awaiting adjudication by an administrative law judge...more
For years the hospital industry has been in an uproar over the mountainous backlog of Medicare claim appeals. Current estimates are that a whopping 650,000 claims are at the Administrative Law Judge level awaiting...more
Originally published in Haig, Business and Commercial Litigation in Federal Courts, Fourth Edition §§ 87:1 et seq. © 2016 American Bar Association. This chapter discusses federal court litigation relating to health care...more