The financial stakes are often very high for providers when statistical sampling and extrapolation is used to calculate an alleged Medicare overpayment. In post-payment audits involving extrapolation, an actual claims denial...more
On April 12, 2019, CMS released a Medicare Learning Network Matters article (MLN) in connection with Change Request (CR) 11042, which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 – Appeals of...more
A March 27, 2018 decision by the United States Court of Appeals for the Fifth Circuit, Family Rehabilitation Incorporated v. Azar, II, No. 17-11337 (“Family Rehab”), potentially paves the way for Medicare providers to seek...more
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
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
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
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
For providers who have received inconsistent or varying reasons for denial while navigating through the Medicare appeals process, the Centers for Medicare & Medicaid Services (CMS) has provided much-needed relief in the form...more
A recent decision out of a United States District Court in Alabama may signal that the playing field traditionally dominated by the government will no longer be so one-sided against providers defending against False Claim Act...more
CMS officially added a new Section 3.9 to the Medicare Program Integrity Manual, effective October 27, 2014. These provisions instruct Medicare Administrative Contractors (MACs) to assign a physician to participate at...more