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Hospitals › Administrative Appeals

Mintz - Health Care Viewpoints

340B Reimbursement Cut Update: 135 Hospitals File Suit to Block Rate Cuts Previously Ruled Unlawful

Mintz - Health Care Viewpoints on

On December 16, 2019, a nationwide coalition of hospitals sued HHS to block implementation of the 340B rate cuts contained in the 2020 Hospital Outpatient Prospective Payment System (“OPPS”) Final Rule. As detailed in our...more

King & Spalding

OIG Hospital Compliance Program Audit Claims $22 Million in Extrapolated Overpayments

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A recent report issued by OIG finding an Indiana community hospital owed over $22 million in extrapolated overpayments carries some important lessons for hospitals audited under OIG’s hospital compliance program. As described...more

K&L Gates LLP

K&L Gates Triage: Recent Developments in Provider v. Payer Litigation -- Medicare Advantage Disputes

K&L Gates LLP on

In this episode, Gary Qualls discusses a recent development in payer litigation, regarding a provider’s recovery of Medicare Advantage payments pursuant to a Medicare Advantage contract. Specifically, a recent federal case...more

Baker Donelson

Court Rejects CMS's "Predicate Facts" Position

Baker Donelson on

In a decision with implications that could go back 35 years, the United States Court of Appeals for the District of Columbia Circuit rejected a CMS interpretation of its reopening rules as that interpretation affects current...more

Baker Donelson

A SLIP on the LIP Adjustment: No Judicial Review Available for Hospitals' LIP Challenges

Baker Donelson on

In Northeast Hosp. Corp. v Sebelius, 657 F.3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit upheld hospitals' challenge to CMS's disproportionate share hospital (DSH) calculation...more

Williams Mullen

Williams Mullen On Call - November 2017

Williams Mullen on

Welcome to the third edition of Williams Mullen On Call. In this edition, we are pleased to provide two very timely interviews. The first interview is with Mandy K. Cohen, MD, MPH, Secretary of the North Carolina Department...more

Baker Donelson

HHS Publishes Final Rule Overhauling the Medicare Appeals Process

Baker Donelson 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

Baker Donelson

D.C. District Ct Applies Prohibition on Administrative and Judicial Review to IRF PPS Rates

Baker Donelson 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

Baker Donelson

CMS Announces "Pause" in QIO Review of Inpatient Admissions

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Last week CMS announced a temporary "pause" in the review of inpatient admissions by the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs). CMS posted this announcement on its Inpatient Hospital...more

King & Spalding

Court Rules Hospitals Must Exhaust HHS Administrative Appeals Process for Medicare Advantage Out-of-Network Payment Dispute

King & Spalding on

According to a Georgia federal district court ruling issued on February 11, 2016, a group of hospitals must exhaust their out-of-network Medicare Advantage (MA) payment dispute through the Department of Health and Human...more

King & Spalding

HHS May Be Forced to Meet Statutory Deadlines for ALJ Appeals

King & Spalding on

On February 9, 2016, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit reversed a district court’s dismissal for lack of jurisdiction in the American Hospital Association v. Burwell case. ...more

Faegre Drinker Biddle & Reath LLP

AHA Proposes Putting RACs on the Rack

Faegre Drinker Biddle & Reath LLP on

The American Hospital Association formally proposed last week that Recovery Audit Contractors (RACs) be fined when their denials are overturned on appeal....more

Baker Donelson

CMS Waves Partial White Flag in Appeals of Payment Status Denials

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For the last several years, hospitals, on the one hand, and the Centers for Medicare and Medicaid Services and its contractors (collectively, CMS), on the other, have been engaged in a spirited dispute over claims denials for...more

Baker Donelson

CMS Revises Part B Billing Policy for Unnecessary Inpatient Admissions

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For many years, CMS policy has been that, if an inpatient admission was denied for medical necessity reasons, the hospital could bill under Part B for only a limited set of services that, significantly, did not include...more

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