News & Analysis as of

Appeals Centers for Medicare & Medicaid Services

CMS Requests Dismissal of Its Nursing Home Arbitration Appeal

by King & Spalding on

On June 2, 2017, CMS filed a motion to dismiss its appeal to the U.S. Circuit Court for the Fifth Circuit of a U.S. District Court decision blocking the agency’s ban on mandatory nursing home arbitration. CMS’s motion did...more

CMS Call to Focus on Changes to the Medicare Claims Appeal Process and Statistical Sampling (June 29)

by Reed Smith on

CMS is holding a call on June 29, 2017 to discuss recent regulatory changes intended to streamline the Medicare administrative appeal processes, reduce the backlog of pending appeals, and increase consistency in...more

Also In The News - Health Headlines - January 2017

by King & Spalding on

Hospitals Have Until January 31, 2017 to Participate in CMS’s 2016 Hospital Appeals Settlement Program – As previously reported here, CMS is offering a new Hospital Appeals Settlement program to allow eligible providers to...more

HHS Announces Final Rule on Medicare Benefit Claim Appeals Process

by King & Spalding on

On January 17, 2017, HHS published its final rule addressing modifications to the Medicare benefit claim appeals process. The final rule seeks to reduce the significant backlog of pending Medicare appeals and streamline the...more

Medicare Appeal Proposal Falls Far Short of Court Mandate

by Faegre Baker Daniels on

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

Healthcare Law Update: December 2016

by Holland & Knight LLP on

Prompt Payment Discounts Not an Anti-Kickback Statute Violation - In United States of Am. et al. ex rel. Ruscher v. Omnicare, No. 15-20629, 2016 WL 6407128 (5th Cir. Oct. 28, 2016), the court of appeals affirmed summary...more

Five Things to Know About CMS's Second Round of Settlements for Hospital Appeals

by Polsinelli on

The Centers for Medicare and Medicaid Services (CMS) announced that beginning December 1, 2016, it is offering to settle certain inpatient-status claims to eligible hospitals willing to withdraw from the administrative...more

CMS to Host Calls on Hospital Appeals Settlement Process (Nov. 16 & Dec. 12)

by Reed Smith on

On November 16, 2016, CMS is hosting a call to provide an update on its latest plans to allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. By...more

CMS Announces Settlement Process for Inpatient Status Claims

by King & Spalding on

On November 3, 2016, CMS announced details for a new Hospital Appeals Settlement program to permit eligible providers to settle certain inpatient status claims currently under appeal. According to CMS, the purpose of the 2016...more

D.C. Circuit Precludes Review of DSH Uncompensated Care Data

by Baker Ober Health Law on

On July 26, 2016, the United States Court of Appeals for the District of Columbia Circuit decided Fla. Health Sciences Ctr. v. Burwell. In that case, the Court analyzed a statutory bar against judicial review of estimates...more

D.C. District Court Strikes Down PRRB's Application of "Self-Disallowance" Jurisdictional

by Baker Ober Health Law on

In Banner Heart Hospital, et al. v. Burwell, the United States District Court for the District of Columbia (Court) held on August 19, 2016, that the Provider Reimbursement Review Board (PRRB) incorrectly declined to hear an...more

District Court Denies Stay in Litigation Over Medicare Appeals Backlog

by King & Spalding on

On September 19, 2016, the U.S. District Court for the District of Columbia rejected a request by HHS to stay proceedings in litigation brought by the American Hospital Association and several providers seeking to compel the...more

D.C. District Ct Applies Prohibition on Administrative and Judicial Review to IRF PPS Rates

by Baker Ober Health Law on

On July 25, 2016, Judge John D. Bates of the United States District Court for the District of Columbia issued a memorandum opinion broadly construing 42 U.S.C. § 1395ww(j) to prohibit administrative or judicial review of a...more

A Favorable, New Climate for Challenging Medicare Appeals

by Latham & Watkins LLP on

Over the past decade, health care providers seeking to challenge Medicare claim denials have faced increasing delays in reaching what many consider the most important step in the Medicare appeals process - a hearing before an...more

CMS Audit Practices: How false can you get?

by McAfee & Taft on

Caring Hearts Personal Home Care Services provided physical therapy and skilled nursing services to homebound Medicare patients. During an audit, CMS determined that Caring Hearts provided services to patients who didn’t...more

Proposed Cardiac, Hip, and Femur Episode Payment Models Are Next Generation from BPCI and CJR

by Baker Ober Health Law on

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 25, 2016, entitled, Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and...more

Court decision spotlights necessary steps to preserve PRRB jurisdiction

by Dentons on

When a health care provider disagrees with a Medicare graduate medical education (GME) reimbursement determination by its Medicare Administrative Contractor (MAC), the provider may bring its claims before an administrative...more

Bankruptcy Courts Lack Subject Matter Jurisdiction Over Medicare Issues, Eleventh Circuit Rules

by Baker Ober Health Law on

In a detailed opinion that likely constitutes the last word on the matter, the Eleventh Circuit recently held in Fla. Agency for Health Care Administration v. Bayou Shores SNF, LLC that bankruptcy courts lack jurisdiction...more

Marketplace Subsidy Notices – What Employers Should Know

As promised by the Centers for Medicare & Medicaid Services (CMS) in late-2015, the Federally-Facilitated Marketplaces (FFMs) have started sending notices informing employers that employees have enrolled in a FFM and were...more

Tenth Circuit Rebukes CMS for Applying Wrong Regulations in Overpayment Action

by King & Spalding on

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

OMHA Expands Settlement Conference Facilitation Program to Part A Appeals: 10 Things to Know

by Polsinelli on

On Feb. 25, 2016, the Office of Medicare Hearings and Appeals (OMHA) conducted a teleconference to address Phase III of the Settlement Conference Facilitation (SCF) project, which also became effective on Feb. 25, 2016. SCF,...more

Second Circuit Invalidates CMS Regulation and Holds That Hospitals Designated as Rural May Apply for an Urban Wage Index While...

by King & Spalding on

On February 4, 2016, the United States Court of Appeals for the Second Circuit struck down HHS regulations that prohibited hospitals from seeking classification as “urban” for purposes of their standardized amount and wage...more

CMS Changes to Cost Report and Appeal Rules Are Now in Effect

by Baker Ober Health Law on

As part of the Outpatient Prospective Payment System (OPPS) final rule published in the Federal Register on November 13, 2015, CMS made noteworthy changes to the Medicare cost report and appeal rules. See 80 Fed. Reg. 70298...more

Court Rules that Medicare and Medicaid Payments to Nursing Home Must Continue Pending Jurisdictional Dispute

by Arnall Golden Gregory LLP on

On October 27, 2015, United States District Judge James S. Moody, Jr. extended a stay of proceedings thereby permitting Bayou Shores SNF, LLC (“Bayou Shores”) to remain viable and continue receiving Medicare and Medicaid...more

Four Key Takeaways on the Expansion of the Medicare Appeals Settlement Conference Project

by Polsinelli on

On October 15, 2015, the Office of Medicare Hearings and Appeals (“OMHA”) conducted a teleconference to address Phase II of the Settlement Conference Facilitation (“SCF”) Pilot, effective October 1, 2015. SCF, launched in...more

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