The CMS Interoperability and Prior Authorization Rules
Podcast — Drug Pricing: How Are Payers Responding to the IRA?
Findings from Gibbins’ Annual Healthcare Bankruptcy Report
A Fond Farewell: Musings on the End of the Medicare Advantage Hospice Carve-In Demonstration
Video: Braidwood v. Becerra – Challenging the Affordable Care Act’s Preventive Services Coverage Provision – Thought Leaders in Health Law
Hospice and Home Health Survey Perspectives: A Conversation with Kim Skehan, VP of Accreditation at CHAP
Transparency and the Open Payments Program
Taking the Pulse, A Health Care and Life Sciences Video Podcast | Episode 173: Improving rural health care with Dr. Kevin Bennett, the Director of the Research Center for Transforming Health and the
Counsel That Cares - The Private Payer's Perspective on Value-Based Care
Podcast: Health Equity – Behind the Buzzwords – Diagnosing Health Care
A Very “Special” Episode: Amid Controversy, CMS Launches the Hospice Special Focus Program
Grace from CMS: Unexpected Good News on HIS and CAHPS Appeals
This Bandwagon Has a Broken Wheel: OIG Joins the Inconsistent Approach to Hospice GIP Claims
Behind the Curtain: Enhanced Provider Enrollment Oversight
Survey Woes: CMS Ramps Up Hospice Survey Program and Consequences
Inflation Reduction Act’s Drug Price Negotiation Provisions – What Now? – Diagnosing Health Care Podcast
A Glimpse Into the Other Side: Understanding the Perspective of Government Enforcers
I Understood There Would Be No Math: Audits, Extrapolations, and a New Set of Rules
Podcast: Inflation Reduction Act’s Drug Price Negotiation Provisions – What’s Next? - Diagnosing Health Care
Quick Takeaways From the 2024 Proposed Hospice Wage Index Rule
Last month, CMS issued three civil monetary penalty (CMP) notices for violations of the hospital price transparency regulations (HPT Rule), which requires hospitals to make public the standard charges of the items and...more
Our firm is seeing an uptick in Medicare demand letters for the recovery of overpayment for skin substitutes, such as WoundFixTM, Biobrane, Dermagraft®, AmnioBand®, or AlloPatch®, used in the treatment of wounds. CMS auditors...more
Here are this week’s curated AG and federal regulatory news stories highlighting key areas in which state and federal regulators’ decisions are having an impact across the US: •AG Frosh Announces Settlement with Alleged...more
As an attorney specializing in healthcare reimbursement, I have focused my practice on helping healthcare providers navigate the Center for Medicare and Medicaid (“CMS”) administrative appeal process. I usually get a call...more
On September 10, 2019, the Centers for Medicare and Medicaid Services (CMS) announced new authority to revoke providers’ Medicare enrollment and any corresponding provider agreements or supplier agreements through revisions...more
Continuing to look for ways to reduce the Medicare administrative law judge (ALJ) appeals backlog, CMS has explored enhancing the role of Qualified Independent Contractors (QICs) to resolve disputed claims earlier in the...more
In response to the disruptive Supreme Court decision on the impact and effect of administrative guidance, HHS has issued a memorandum suggesting that CMS's ability to enforce some of its payment policies may be limited by the...more
The Centers for Medicare and Medicaid Services (CMS) published the Price Transparency Requirements for Hospitals to Make Standard Charges Public Final Rule (the Final Rule, effective January 1, 2021), in the Federal Register...more
Two United States District Courts in Louisiana and Illinois issued split decisions within two weeks of each other on the dire financial issues facing providers every day under the discretionary “penal recoupment” system the...more
When the Centers for Medicare and Medicaid Services (CMS), through a Medicare contractor, conducts a post-payment audit of a provider’s Medicare reimbursements and determines that the provider may have received an...more
The Centers for Medicare and Medicaid Services (CMS) made a number of recent changes to expand the Settlement Conference Facilitation (SCF) process for providers and suppliers mired in the backlog of appeals at the...more
Medicare providers who have overpayments with pending requests for Administrative Law Judge (ALJ) hearings filed on or before March 31, 2019 may now take advantage of the renewed Settlement Conference Facilitation (SCF)...more
With the introduction of RACs, ZPICs, and UPICs, the administrative process for Medicare payment disputes has resulted in three to five year delays in adjudicating claims while providers are faced with almost certain...more
The HHS Office of the Inspector General (“OIG”) has reported the results of a study assessing service and payment denials by Medicare Advantage Organizations (“MAOs”). The study revealed “widespread and persistent MAO...more
Recent opinions by the Fifth Circuit, the Northern and Southern Districts of Texas, and the District of South Carolina offer hope to providers seeking relief from substantial monetary recoupments during the Medicare appeals...more
The current, ultimate dilemma in the health care reimbursement legal arena is the catastrophically long wait for a hearing with an Administrative Law Judge (“ALJ”) with the Office of Medicare Hearings and Appeals (“OMHA”)....more
In a recent decision, the Northern District of Texas, Dallas Division, granted a health care provider a preliminary injunction to prevent the Centers for Medicare & Medicaid Services ("CMS") from withholding Medicare payments...more
Medicare’s implementation of post-payment review through overly aggressive zone program integrity contractors (ZPICs) and unified program integrity contracts (UPICs), combined with an ineffective review process at the first...more
Providers and suppliers who have been assessed overpayments for Medicare services are entitled, by statute, to a stay of recoupment while the provider or supplier’s appeal is pending – but only at the first two levels of...more
On June 28, 2018, the U.S. District Court for the Northern District of Texas granted a motion for preliminary injunction which prevents CMS from recouping alleged overpayments of approximately $7.5 million from Family...more
A home health agency has scored a second win in its fight to prevent CMS from withholding Medicare payments (to effectuate a recoupment of alleged overpayments), at least for the time being. We previously reported on the...more
The Department of Health and Human Services (HHS) announced on November 3, 2017 additional settlement options for providers and suppliers in an effort to improve the Medicare claims appeals process, which included (1) the Low...more
In an effort to resolve its backlog of Medicare appeals, the Department of Health & Human Services’ Office of Medicare Hearings and Appeals (OMHA) established a Settlement Conference Facilitation (SCF) pilot program in June...more
HHS’s Office of Medicare Hearings and Appeals (OMHA) has long faced a backlog in Medicare appeals to Administrative Law Judges (ALJs). In an effort to address this backlog, OMHA established a Settlement Conference...more
In preparation for the upcoming expansion of its Settlement Conference Facilitation (SCF) program, the Office of Medicare Hearings and Appeals (OMHA) has directed interested providers and suppliers to review the SCF Expansion...more