In what passes for neon lights in the regulatory world, CMS said Medicare Advantage (MA) plans must follow the two-midnight rule, its case-by-case exception and the inpatient-only (IPO) list, according to the final 2024 rule...more
With many hospitals well into their FY 2021 Medicare cost report preparation, here is a brief reminder of the process required for protesting items, as well as a summary of two new developments for Medicare Graduate Medical...more
The Office of Inspector General (OIG) for the Department of Health and Human Services recently announced a new addition to its work plan: auditing whether payments made by Medicare for COVID-19 inpatient discharges billed by...more
In the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (2020 OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) established a prior authorization process and...more
On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Quality, Safety & Oversight memorandum QSO-20-27-Hospital (QSO Memo), addressed to state survey agencies to provide guidance to independent...more
On December 12, 2019, OIG released a report finding that CMS made an estimated $94 million in incorrect Medicare incentive payments to acute-care hospitals for using electronic health records (EHRs) over an audit period from...more
Beginning in July, 2019, the Centers for Medicare & Medicaid Services (CMS) will direct Medicare Part A/B Macs to perform claim validation edits and return all claims to hospital providers if the address included on their...more
On June 1, 2018, CMS issued further guidance for reporting and reviewing final adverse legal actions (ALAs) in provider enrollment applications. In Transmittal 797, which replaces Transmittal 784 to the Medicare Program...more
In a recent edition of MLN Connects, CMS reminded health care providers and suppliers of their obligation to report changes in ownership as part of their conditions of participation under Medicare....more
The HHS OIG recently published a report detailing CMS’s and Medicare Administrative Contractor’s (“MACs’”) ongoing issues in the outlier payment reconciliation process. A previous 2012 review identified 465 cost reports that...more
The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) has issued its Work Plan for Fiscal Year 2017. The annual Work Plan provides a summary of new, revised, and continuing reviews for DHHS...more
On March 10, 2017, Judge John Bates of the U.S. District Court for the District of Columbia upheld CMS’s three-year cost report reopening limitation, as applied to “predicate fact” determinations. The regulation at issue is...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
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
On August 19, 2016, the United States District Court for the District of Columbia granted a group of hospitals’ motion for summary judgment against HHS in a challenge of the Provider Reimbursement Review Board’s (PRRB) denial...more
According to press reports, on May 4, 2016, CMS directed Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) tasked with reviewing the appropriateness of short stay inpatient claims under the...more
The Centers for Medicare & Medicaid Services (CMS) has implemented a revised payment system for Long-Term Care Hospitals (LTCHs). The changes, which became effective on October 1, define two separate payment categories for...more
On July 8, 2015, the Centers for Medicare and Medicaid Services (“CMS”) released a Proposed Rule regarding the 2016 Hospital Outpatient Prospective Payment System (“OPPS”). The Proposed Rule, in addition to proposing updates...more
MACS to Hold Certain 2015 Date-of-Service Claims – CMS announced on December 29, 2014, that Medicare Administrative Contractors will hold claims containing 2015 services paid under the Medicare Physician Fee Schedule (MPFS)...more
On August 2, 2013, the Centers for Medicare and Medicaid Services (“CMS”) released the final rule for the 2014 Medicare Inpatient Prospective Payment System (“IPPS”), effective October 1, 2013.[1] Introduced in the IPPS...more
On February 24, 2014, CMS released additional guidance addressing implementation of the revised inpatient hospital admission standards adopted in the 2014 IPPS Final Rule and new instructions to the Medicare Administrative...more
Earlier this month, CMS posted three new documents related to the 2-midnight rule for inpatient admissions on its webpage for inpatient hospital reviews: new FAQs, as well as CMS directions for selecting hospital claims for...more
In early November, CMS released additional guidance regarding implementation of provisions of the 2014 Inpatient Prospective Payment System (IPPS) Final Rule that apply to inpatient admissions. For more background regarding...more