News & Analysis as of

Appeals Medicare

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

Appeals Court Upholds Charity Care Patient Population Exclusion from DSH Payments

by King & Spalding on

On May 9, 2017, the U.S. Court of Appeals for the District of Columbia Circuit affirmed a lower court ruling denying hospitals from including New Jersey Charity Care Program (NJCCP) patients in the hospitals’ disproportionate...more

HHS Final Rule on Medicare Coverage Determination Appeals Process Takes Effect

by King & Spalding on

HHS’s final rule revising procedures for ALJ and Medicare Appeals Council level appeals, announced on January 17, 2017, took effect on March 20, 2017....more

Fourth Circuit Rejects Retirees’ Claim for Vested Health Benefits

The Fourth Circuit upheld an employer’s unilateral decision to amend a collective bargaining agreement to cap employer contributions to retiree health benefits and freeze Medicare reimbursements for hourly retirees...more

False Claims Act Alert: Fourth Circuit Punts on Sampling and Extrapolation

by Hogan Lovells on

Tuesday, the Fourth Circuit Court of Appeals ruled in the interlocutory appeal in United States ex rel. Michaels v. Agape Senior Community, Inc.. In an opinion considering two significant questions arising under the qui tam...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

HHS Publishes Final Rule Overhauling the Medicare Appeals Process

by Baker Ober Health Law on

The Department of Health and Human Services (HHS) published its final rule revamping the Medicare appeals process at the Administrative Law Judge (ALJ) level on January 17, 2017. The final rule extensively revises federal...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

Birmingham Medical News: End in Sight for Medicare ALJ Backlog?

by Burr & Forman on

As providers who are currently undergoing a Medicare claims appeal know, there is a lengthy delay to having an appeal actually heard by an Administrative Law Judge (“ALJ”). Some estimates indicate that it will currently take...more

HHS Ordered To Eliminate Medicare Appeals Backlog By 2021

by BakerHostetler on

On January 4, 2017, the U.S. District Court for the District of Columbia rejected a request by the Secretary of HHS asking the court to reconsider its decision that requires HHS to eliminate the backlog of Medicare claims...more

Judge Denies HHS’s Request to Rescind Timeline to Eliminate the Medicare Appeals Backlog

by King & Spalding on

On January 4, 2017, the court in the American Hospital Association (AHA) v. Burwell litigation denied HHS’s motion to reconsider, which means that HHS must comply with the court’s timeline to eliminate the Medicare appeals...more

HHS Claims it is Unable to Meet Court-Ordered Targets to Resolve Medicare Appeals Backlog

by King & Spalding on

The U.S. District Court for the District of Columbia issued an order on December 5, 2016 compelling HHS to meet certain annual targets to resolve its backlog of hundreds of thousands of pending Medicare claim appeals. HHS...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

U.S. District Court for District of Columbia Requires HHS to Eliminate Medicare Appeals Backlog by December 31, 2020

by Baker Ober Health Law on

On December 5, 2016, a U.S. District Court for the District of Columbia granted summary judgment in American Hospital Association, et al., v. Burwell, in favor of the American Hospital Association (AHA) in its quest to reduce...more

It Ain't Over 'Till It's Over – First Circuit Rejects Settlement Agreements Between Providers and Intermediary and Upholds Cost...

by Baker Ober Health Law on

On October 27, 2016, a three-judge panel for the United States Court of Appeals for the First Circuit issued an opinion concluding that a Medicare fiscal intermediary (Intermediary) does not have the authority to enter into a...more

Court Orders HHS to Fix the Medicare Appeals Backlog by the End of 2020

by Reed Smith on

Medicare providers with pending cases at the administrative law judge (“ALJ”) level received positive news last week as a federal judge for the United States District Court for the District of Columbia (the “Court”) granted...more

Supreme Court Implied False Certification Case Reargued to First Circuit

by Foley & Lardner LLP on

On Tuesday, October 25, 2016, a three-judge panel of the United States Court of Appeals for the First Circuit heard argument in United States ex rel. Escobar, et al. v. Universal Health Services, Inc. This case was sent back...more

Recent Developments in Litigation Challenging the Medicare Appeals Delays: Is Victory Likely for Medicare Providers?

by Latham & Watkins LLP on

On September 19, 2016, the U.S. District Court for the District of Columbia (D.D.C.) refused to stay a highly anticipated case seeking to force the government to comply with statutory deadlines governing the Medicare appeals...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

Court Rules in Favor of Hospitals in Bad Debt Collection Effort

by Baker Ober Health Law on

On July 25, 2016, the United States District Court for the District of Columbia issued an opinion favoring provider flexibility in the reasonable collection of Medicare bad debt. Winder HMA, LLC, et al. v. Sylvia Burwell. The...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

Medicare Advantage Plan Arbitration Clauses Preempted by Medicare Appeals Process

by BakerHostetler on

The Arizona Supreme Court, in an interesting case involving a Medicare-related coverage dispute between a Medicare Advantage plan administrator, United Behavioral Health (UBH), and two inpatient psychiatric care providers,...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

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