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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
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
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
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
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
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
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
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
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 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