News & Analysis as of

Inpatient Billing

Are You Ready for AB 72?

by Buchalter on

To protect patients from receiving an unexpected surprise bill when they seek care at in-network facilities from out-of-network providers, Governor Brown signed AB 72: California’s surprise out-of-network law. The new law...more

When your Hospital-of-Choice is In-Network but, SURPRISE, your Anesthesiologist is Not: California’s AB-72 and Other State...

Regardless of a patient’s diligence in selecting an in-network hospital, ambulatory surgery center, or other health facility for treatment, patients are still being saddled with surprisingly high medical bills that include...more

How Concerned Should Insurers be About Punitive Damages in California?

by Robins Kaplan LLP on

The California Court of Appeal recently published another opinion about the Nickerson v. Stonebridge Life Insurance case. The court held to its maximum 10:1 punitive-to-compensatory-damages ratio and analyzed whether this...more

Five Things to Know About CMS's Second Round of Settlements for Hospital Appeals

by Polsinelli on

The Centers for Medicare and Medicaid Services (CMS) announced that beginning December 1, 2016, it is offering to settle certain inpatient-status claims to eligible hospitals willing to withdraw from the administrative...more

Eighth Circuit Determines that Compliance with Reasonable Interpretation of Government Regulation Sufficient to Avoid FCA...

by Dorsey & Whitney LLP on

The Centers for Medicare and Medicaid Services (“CMS”) establishes requirements for how medical procedures must be performed for a medical provider to seek payment for those procedures. Seeking payment without properly...more

Prevailing in an Era of Regulatory Enforcement – Balancing Risk and Compliance [Expect Focus – Vol. II, July 2016]

by Carlton Fields on

IN THE SPOTLIGHT - - SEC Sanctions Unregistered EB-5 Investments Broker SECURITIES - - FINRA to Assess Member Firms’ Culture - SEC Seeks Fund Responses to Distribution-In-Guise Guidance...more

OIG Recommends Eliminating Provider-Based Designation for Facilities Owned by Hospitals

by King & Spalding on

In a report released on June 17, 2016, OIG renewed its call for CMS to either eliminate the provider-based designation, which allows facilities owned by and integrated with a hospital to bill Medicare as a hospital outpatient...more

OIG Continues its Focus on GIP Abuse: What Hospice Providers Need to Know

by Arnall Golden Gregory LLP on

On March 31, 2016, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) issued a report on hospice billing for general inpatient care (GIP). According to the OIG, hospices billed Medicare for...more

OIG Examines Hospice Medicare Billing for General Inpatient Care

by Reed Smith on

According to a recent OIG report, hospices billed inappropriately almost one-third of Medicare general inpatient care (GIP) stays in 2012, resulting in $268 million in inappropriate Medicare payments. The GIP level of care...more

OIG Issues Critical Medical Review Report of Hospice GIP

by Morgan Lewis on

The report shows significant lapses in 2012 GIP service claims and recommends that CMS implement additional oversight and enforcement options....more

Hospice Care Eligible Patient Certification is a “Condition of Payment” Under False Claims Act

by Saul Ewing LLP on

In order to state a cognizable claim under the False Claims Act (“FCA”) on a false certification theory, a plaintiff must allege that a defendant failed to comply with a federal statute or regulation that was a “condition of...more

Annual RAC Report Shows Significant Drop in Recoveries by CMS in 2014

by King & Spalding on

On October 15, 2015, CMS released its annual recovery auditing report to Congress. CMS’s Recovery Auditor (RAC) program identifies and corrects improper payments through a combination of prepayment and post-payment reviews,...more

OIG Hospital Compliance Audits: Is Your Number Up? Are You Ready?

by Baker Donelson on

In its Work Plan for Fiscal Year 2012, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) announced it would begin reviews of Medicare payments to hospitals to determine compliance...more

GAO Finds Limited Hospital Impact from Hospital Value-Based Purchasing Program

by Reed Smith on

According to a recent Government Accountability Office (GAO) report, bonuses and penalties triggered by the Medicare Hospital Value-based Purchasing (HVBP) program have had no apparent impact on quality measure performance...more

Uncertainty Continues for Two-Midnight Rule's Payment Reduction

by Baker Ober Health Law on

In Shands Jacksonville v. Burwell [PDF], No. CV 14-1477, 2015 WL 5579653, (D.D.C. Sept. 21, 2015), the United States District Court for the District of Columbia gave the Secretary of the Department of Health and Human...more

Two-Midnight Rule Update

The Centers for Medicare and Medicaid Services (CMS) announced a further delay, through December 31, 2015, of the Recovery Auditors’ (RA) audits of the “Two-Midnight” Rule. Congress previously passed a law delaying...more

CMS Releases CY 2016 OPPS Proposed Rule With Updates to Two-Midnight Rule and Other IPPS Proposals

by BakerHostetler on

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2016 outpatient prospective payment system (OPPS)/ambulatory surgical center (ASC) payment system proposed rule that...more

CMS Proposal Broadens Medicare Inpatient Reimbursement Eligibility Under the “2-Midnight Rule"

by McDermott Will & Emery on

On July 1, 2015, the Centers for Medicare & Medicaid Services (CMS) released proposed updates to the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for Calendar Year...more

Changes to the “Two-Midnight Rule” on the Horizon

On July 1, CMS published proposed changes to the so-called “Two-Midnight Rule,” which currently governs when inpatient hospital admissions are entitled to Medicare Part A payment. The proposed changes were announced in a...more

CMS Pays $1.3 Billion to Hospitals for Settlements of Medicare Inpatient Appeals

by Baker Ober Health Law on

On June 11, 2015, CMS announced that it had entered into settlements with over 1,900 hospitals for over 300,000 disputed inpatient billing claims. CMS updated its website dedicated to inpatient hospital reviews, noting that...more

Also In The News - Health Headlines - March 2015 #5

by King & Spalding on

CMS Announces Billing Changes for Certain Inpatient-Only Procedures – Effective April 1, 2015, CMS will allow payment for Inpatient-Only procedures provided in an outpatient setting on the date of the inpatient admission, or...more

Corridors Spring 2015 - News for North Carolina Hospitals

by Poyner Spruill LLP on

In This Issue: - Nonprofit Hospitals Face Additional Regulatory Burdens in Financial Assistance and Debt Collection - Placing Medicare Beneficiaries Into "Observation Status" - Recent Second Circuit Decision...more

Medicare Hospital Compliance Reviews are Legal and Sound, According to OIG

The Office of Inspector General for the Department of Health and Human Services (OIG) recently defended its practices pertaining to hospital compliance reviews in a published response to a letter from the American Hospital...more

CMS Finalizes OPPS Rule Packaging Pathology Services Ordered for Hospital Outpatients

As part of the Outpatient Prospective Payment System (OPPS) Rule issued last week, the Centers for Medicare & Medicaid Services (CMS) finalized its proposal to conditionally package certain ancillary services assigned to APCs...more

CMS Offers To Settle All Acute Care Inpatient Claim RAC Appeals

by Burr & Forman on

CMS is offering to pay hospitals 68 percent of the allowable amount for all claims that are currently on appeal. Specifically, CMS is offering to settle "inpatient status" claims at 68 percent of the "net paid amount" within...more

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