Appeals Medicare

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

Hospice Cap Demand Group Appeal Deadline

As you likely are aware, Medicare hospice payments were reduced by two percent in accordance with a sequestration order issued March 1, 2013, pursuant to Section 251A of the Balanced Budget and Emergency Deficit Control Act....more

Federal Appeals Court Reverses Conviction of Mental Health Program Director

In a recently released decision, the United States Court of Appeals for the Eleventh Circuit reversed the conviction of a former community mental health program director who was convicted after trial of conspiring to commit...more

Stark Litigation: The Tuomey Saga Draws to a Close

In what may be the penultimate chapter of the long–running saga of the Tuomey case, the Fourth Circuit affirmed the final judgment and award in favor of the government in its case against Tuomey Healthcare System, Inc....more

Ninth Circuit Lowers Public Disclosure Bar

In a reversal of 23-year-old precedent, the US Court of Appeals for the Ninth Circuit ruled en banc in two consolidated cases that a False Claims Act (FCA) (31 U.S.C. § 3729, et seq.) relator may qualify as an “original...more

Recent Ninth Circuit En Banc Decision Makes It Easier for Relators to be an Original Source and the First- to-File

On July 7, 2015, the United States Court of Appeals for the Ninth Circuit issued an en banc decision that potentially makes it easier for relators to prevail on pending False Claim Act qui tam suits and bring new actions in...more

"The Stark Law has become a booby trap…" Says the Federal Appeals Court. Why Health Care Providers Should Heed the Warning

After reading through the hundreds of pages of the District Court's and Appeals Court's decisions, including the recent Fourth Circuit Court of Appeals decision that was filed on July 2, 2015, one thing is certain: Mixing one...more

Tuomey’s Appeal of $237M False Claims Act Judgment Denied by the Fourth Circuit

In This Issue: - Background - Tuomey’s Second Appeal to the Fourth Circuit - The Trial Court’s Grant of a New Trial - Tuomey’s Request for Judgement as a Matter of Law on the Stark Law and FCA...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

Senate Finance Committee Holds Hearing Regarding Medicare Appeals Backlog

On April 28, 2015, the Senate Finance Committee held a hearing titled “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.” The hearing included testimony from Office of Medicare Hearings...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

Medicare and Medicaid Appeal Deadlines and Procedures: Laws that EVERY Health Care Provider Should Know

If you are a physician, most likely, you are not a lawyer. And vice versa. While there are exceptions, generally, the professions of physicians and attorneys are mutually exclusive. Personally, one reason I went to law...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

7th Circuit Court of Appeals Creates Expansive Definition of “Referral” Under the Anti-Kickback Statute

On February 10, 2015, in United States v. Patel (Case No. 14-2607), the Seventh Circuit Court of Appeals ruled that a physician makes a “referral” within the meaning of the federal health care programs Anti-Kickback Statute...more

Second Circuit Revives Medicare Beneficiaries’ Observation Status Suit

On January 22, 2015, the U.S. Court of Appeals for the Second Circuit reversed a decision by the U.S. District Court for the District of Connecticut dismissing a lawsuit by Medicare beneficiaries alleging deprivation of due...more

First Circuit Reaffirms FCA’s “First-to-File” Bar as a Broad Jurisdictional Limit

In early December 2014, the United States Court of Appeals for the First Circuit reaffirmed that circuit’s broad interpretation of the False Claims Act’s “first-to-file” bar, 31 U.S.C. § 3730(b)(5), in United States ex rel....more

AHA Responds to House Bill Concerning RACs and Two-Midnight Rule

In a December 18, 2014 letter to U.S. Representative Kevin Brady, the American Hospital Association (AHA) voiced its opinion on a discussion draft of the Hospital Improvements for Payment Act of 2014 (HIP). The House Ways and...more

Eleventh Circuit Limits Scope of FCA Whistleblower Suit

Late last month, a three-judge panel of the Eleventh Circuit Court of Appeals reinstated portions of a former executive’s False Claims Act (“FCA”) whistleblower action against Health Management Associates Inc. (“HMA”),...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

Fifth Circuit Holds Multiple Disclosures Establish Loss Causation in Securities Action

The US Court of Appeals for the Fifth Circuit recently held that multiple partial “corrective” disclosures collectively may satisfy the requirements of pleading loss causation in a securities fraud class action, even if no...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

7th Circuit Defines "Worthless Services" Under the False Claims Act

That’s the upshot from U.S. ex rel. Absher v. Momence Meadows Nursing Center, Nos. 13-1886 & 13-1936 (Aug. 20, 2014), a recent decision from the Seventh Circuit (authored by Judge Manion) that addressed the worthless-services...more

Medicare Beneficiaries Sue HHS Over 489-Day Backlog in ALJ Appeals

The Center for Medicare Advocacy (CMA) filed a complaint last week on behalf of five Medicare beneficiaries in federal district Court in Connecticut requesting a court order requiring the Secretary of HHS to clear a massive...more

The Seventh Circuit Significantly Heightens the Bar for Proof in False Claims Act "Worthless Services" Cases

The United States Court of Appeals for the Seventh Circuit recently dealt a stinging blow to the False Claims Act (FCA) plaintiff's bar in United States ex. rel. Absher v. Momence Meadows Nursing Center, Inc. et al., Case...more

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