News & Analysis as of

Medicare’s Recovery Audit Program (RAC Audits), An Update For Physicians

As many physicians now realize, Recovery Audit Contractors ("RAC") hired by Medicare have turned their attention from hospitals and are now actively pursuing claims submitted by physicians. An audit by a RAC can put a...more

OMHA Holds Medicare Appellant Forum

On February 12, 2014, the Office of Medicare Hearings and Appeals (OMHA) held a “Medicare Appellant Forum” in Washington, DC. The event was well-attended, with 300 people signed up to be present in-person, and 500 who signed...more

The Latest Zpic Target: Medicare Cost Reports

When Medicare was created in 1966, Medicare paid participating providers (e.g. hospitals and skilled nursing facilities) based on a portion of their costs. Medicare’s portion of costs was determined by multiplying total costs...more

Resubmission of Hospital Claims

On February 13, CGS Administrators, the Parts A and B Medicare Administrative Contractor for Kentucky and Ohio, relayed instructions to Medicare hospitals paid under the Inpatient Prospective Payment System from the Centers...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: Providers' Appeal Period Not Extended by Doctrine of Equitable Tolling

Under the Medicare statute and implementing regulation, providers have 180 days from the issuance of a Notice of Program Reimbursement (NPR) in which to file an appeal to the Provider Reimbursement Review Board (PRRB). This...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

Court Rules That Medicare DSH Statute Means What It Says

In recent times, the provider community has enjoyed success in challenging the Secretary’s interpretation of the Medicare disproportionate share hospital (DSH) adjustment provisions and what, the providers have maintained,...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

Providers Again Win in Medicare Disproportionate Share Adjustment Challenge

In a 2011 decision, Northeast Hospital Corp. v. Sebelius, 657 F. 3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit ruled for the providers in a challenge to the Secretary’s...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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