News & Analysis as of

Appeals Centers for Medicare & Medicaid Services (CMS) Provider Payments

King & Spalding

D.C. Circuit Rejects Critical Access Hospital’s Appeal for Medicare Payments to On-Call Specialty Physicians

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On April 15, 2022, the D.C. Circuit affirmed the denial of a California hospital’s request to obtain critical access hospital cost reimbursement from Medicare for the costs incurred to keep non-emergency specialty physicians...more

Health Care Compliance Association (HCCA)

CMS to Take Back Money It Returned Under Site-Neutral Payment Policy

Report on Medicare Compliance 30, no. 2 (January 18, 2021) - CMS is taking back money from hospitals for outpatient clinic visits provided in 2019 at excepted off-campus provider-based departments (PBDs) after returning...more

Baker Donelson

D.C. Appeals Court Upholds CMS's Authority to Limit Payment for E&M Services at Off-Site Provider-Based Locations

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The United States Court of Appeals for the District of Columbia recently upheld CMS's authority to expand site-neutral payment reductions for evaluation and management (E&M) services provided at longstanding off-campus...more

Skadden, Arps, Slate, Meagher & Flom LLP

Medicare and Medicaid Developments in Health Care Bankruptcies

In 2019, the increased wave of distressed health care companies continued, and with downward pressure on reimbursement rates, regulatory changes, decreased occupancy rates and technological advances, this trend is unlikely to...more

King & Spalding

Hospitals Ask Appeals Court to Affirm Their Victory in Off-Campus Provider-Based Department Rate Cut Saga

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On Thursday, February 20, 2020, hospitals represented by King & Spalding that operate excepted off-campus provided-based outpatient departments (PBDs) filed their brief in federal appeals court to preserve the victory they...more

King & Spalding

CMS Publishes Final Rule for CY 2020 Hospital Outpatient Prospective Payment System

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n November 1, 2019, CMS posted the final rule establishing the payment rates for the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgery Center (ASC) Payment System for calendar year (CY) 2020...more

Bass, Berry & Sims PLC

Third Circuit Holds Allegations of Improper Compensation Methodologies under the Stark Law Survive Motion to Dismiss

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The U.S. Court of Appeals for the Third Circuit recently issued a False Claims Act (FCA) decision calling into question productivity-based physician compensation structures under the Stark Law, in reliance on a controversial...more

King & Spalding

Supreme Court Delivers Victory to Providers in Allina DSH Part C Case in a Decision with Broad Implications

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In a major win for providers that serve a disproportionate share of indigent patients, the Supreme Court today upheld the D.C. Circuit’s earlier decision invalidating CMS’s policy to treat beneficiaries enrolled in Part C...more

Mintz - Health Care Viewpoints

Update on Azar v. Allina Health Services: Supreme Court Hears Oral Argument on When CMS Must Use Formal Rulemaking

On January 15, 2019, the Supreme Court heard oral arguments in Azar v. Allina Health Services, a prominent case involving a challenge by hospitals over when Medicare’s instructions to its contractors impact a “substantive...more

Mintz - Health Care Viewpoints

Supreme Court to Decide Critical Case on When CMS Must Use Formal Rulemaking when Instructing Medicare Contractors

On January 15, 2019, the U.S. Supreme Court will hear arguments in a hotly-contested case involving a challenge by hospitals over when Medicare’s instructions to its contractors impact a “substantive legal standard” and thus...more

Baker Donelson

Supreme Court Grants Review in Allina Health Services Case

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Is the Department of Health and Human Services (HHS or the government) required to engage in notice and comment rulemaking when it changes a requirement that has an important impact on hospitals' reimbursement? As we reported...more

Baker Donelson

A SLIP on the LIP Adjustment: No Judicial Review Available for Hospitals' LIP Challenges

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In Northeast Hosp. Corp. v Sebelius, 657 F.3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit upheld hospitals' challenge to CMS's disproportionate share hospital (DSH) calculation...more

Sheppard Mullin Richter & Hampton LLP

CMS Rolls Out Provider Appeals Settlement Efforts

This year CMS is rolling out two new programs aimed, finally, at helping to settle certain types of pending provider reimbursement appeals. The programs are the Low Volume Appeals Initiative and Settlement Conference...more

Baker Donelson

Hospitals Plagued by HHS's 2012 Medicare DSH Calculation Obtain Relief from the D.C. Circuit

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Hospitals affected by HHS's 2014 decision to include Medicare Part C enrollees as part of the Medicare fraction of the disproportionate share calculation obtained relief late last month when that position was voided by the...more

Baker Donelson

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

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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

Baker Donelson

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

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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

Baker Donelson

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

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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

Latham & Watkins LLP

A Favorable, New Climate for Challenging Medicare Appeals

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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

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