Appeals Centers for Medicare & Medicaid Services

News & Analysis as of

CMS's "At a Collection Agency" Bad Debt Policy - Confusion Continues

As we reported in previous Payment Matters articles, the United States District Court for the District of Columbia has issued inconsistent opinions regarding Medicare's policy not to allow bad debt when that bad debt is still...more

Key Ruling In False Claims Act Case Could Have Important Implications For Defendants

A recent decision out of a United States District Court in Alabama may signal that the playing field traditionally dominated by the government will no longer be so one-sided against providers defending against False Claim Act...more

Senate Committee Passes Bill Addressing Medicare Appeals Inefficiencies

On June 3, 2015, the Senate Finance Committee passed an original bill that aims to streamline and improve the Medicare Audit and Appeals Process. The Medicare appeals process has recently faced scrutiny from industry leaders...more

Washington Healthcare Update

This Week: House Ways & Means Committee Holds Markup; Makes Significant Legislative Changes to Health Care Bills... Senate Finance Committee Holds Markup on Medicare Appeals Process Bill... CMS Issues Final Rule on...more

New CMS Ruling on DSH Appeals for FY 2004 and Earlier

It’s a measure of the backlog in DSH (for Disproportionate Share Hospital) payment appeals that CMS is still issuing rulings for appeals applicable to treatment of patients before October 1, 2004. On April 24 CMS issued...more

FAR Part 12 Applies to CMS Orders on Federal Supply Schedule Contract

On Tuesday, March 10, 2015, the Court of Appeals for the Federal Circuit reversed and remanded a decision by the Court of Federal Claims, which permitted the Centers for Medicare and Medicare Services (CMS) to include...more

Health Law Pulse - February 2015

On January 23, 2015, the United States Department of Labor (DOL) filed a notice of appeal with the United States Court of Appeals for the District of Columbia (District Court) challenging two rulings in the case of Home Care...more

CMS Instructs MACs to Participate in ALJ Hearings

CMS officially added a new Section 3.9 to the Medicare Program Integrity Manual, effective October 27, 2014. These provisions instruct Medicare Administrative Contractors (MACs) to assign a physician to participate at...more

HHS Seeks Public Input To Address Growing Backlog of Medicare Appeals

The Office of Medicare Hearings and Appeals (OMHA), a division of HHS that administers the Administrative Law Judge (ALJ) hearing program for Medicare claims appeals, recently issued a Request for Information (RFI) seeking...more

One Last Shot at Meeting October Deadline on Two-Midnight Appeals

On October 27, 2014, the Centers for Medicare & Medicaid Services (CMS) made a concession—a very small one—to hospitals racing against the looming October 31, 2014, deadline for accepting the offer of 68 cents on the dollar...more

Court Affirms CMS's Adjustments to Wage Index

Deferring to CMS, the United States Court of Appeals for the Sixth Circuit recently upheld the agency’s treatment of hospitals’ payments to employees for wage index purposes. Atrium Medical Center v. U.S. Dept. of Health &...more

Health Law Pulse - September 2014

In This Issue: - U.S. Court of Appeals Holds that Physicians’ Employer is Personally Liable for Costs Associated with The H- 1B Process and Obtaining a Waiver of the Two- Year Home Residency Requirement - CMS...more

Attention Hospitals! Act Now To Get 68 Cents For Your Medicare Dollar!

It’s no secret that CMS is drowning in appeals from denials of Medicare claims for inpatient care. The number of pending appeals was estimated at half a million back in February, and it’s only grown since then. One reason...more

CMS Offers Deal to Hospitals to Drop RAC Appeals

On August 29, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a deal to hospitals willing to drop pending inpatient-status claims appeals. These appeals have grown exponentially in recent years due to the...more

Special (Limited) CMS Offer to Settle Claims on Appeal

With little fanfare just before the Labor Day weekend, CMS announced a program in which it would enter into administrative agreements with eligible providers in exchange for the providers’ withdrawal of pending appeals...more

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

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 Rules Equitable Tolling Cannot Be Used To Extend Deadline For Filing Medicare Part A Reimbursement Appeals

On January 21, 2103, the U.S. Supreme Court unanimously held in Sebelius v. Auburn Regional Medical Center that the Medicare statute does not permit the time period for filing an appeal with the Provider Reimbursement Review...more

AHA Survey Identifies Continuing Problems with Medicare RAC Program

The American Hospital Association (AHA) published its RACTRAC Survey results for the third quarter of 2012. The AHA created the survey in response to the lack of information released by CMS on its Medicare RAC program. For...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

CMS Raises Threshold Amounts for Medicare Appeals

CMS recently issued a notice [PDF] that the amount in controversy necessary to pursue certain appeals will increase beginning January 1, 2013. The increase in the amount in controversy threshold relates to Administrative Law...more

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