News & Analysis as of

Overpayment Administrative Law Judge (ALJ)

Hendershot Cowart P.C.

CMS, Qlarant Scrutinizing Medicare Claims for Skin Substitute Treatments

Hendershot Cowart P.C. on

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

Health Care Compliance Association (HCCA)

Provider Wins $2M Appeal at ALJ Over Modifier 25, Random Sample

Report on Medicare Compliance 30, no. 11 (March 22, 2021) - A cancer center has won its appeal of $2 million in Medicare claim denials in a case about modifier 25 and the extrapolation of an overpayment. Problems with the...more

Health Care Compliance Association (HCCA)

DAB Affirms OIG's $1.32M Penalty on Provider for Breaching CIA

Report on Medicare Compliance 29, no. 23 (June 22, 2020): The HHS Departmental Appeals Board (DAB) has upheld the largest stipulated penalty imposed by the HHS Office of Inspector General (OIG) in years. OIG fined...more

Arnall Golden Gregory LLP

CMS Expands Authority to Revoke Providers’ Medicare Enrollment While Medicare Overpayment Appeals are Pending ALJ Review

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

Proskauer - Whistleblower Defense

ARB: “Hinting” at Filing a Whistleblower Complaint is Not Protected Activity

On October 31, 2019, the ARB held that an employee who merely “hints” that he or she intends to file a whistleblower complaint has not engaged in protected activity sufficient to invoke the whistleblower protection provision...more

Arnall Golden Gregory LLP

Two Recent Federal Court Decisions Split on Family Rehabilitation Precedent: Fifth Circuit May Once Again Determine Providers’...

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

Kramer Levin Naftalis & Frankel LLP

Fifth Circuit Joins Circuit Split Upholding Bankruptcy Court Jurisdiction to Hear Social Security Claims: Case Has Impact for...

In a case that could impact health care bankruptcies, where jurisdiction over Medicaid and Medicare claims in bankruptcy are often disputed, the Fifth Circuit, in In re Benjamin v. U.S. Social Sec. Admin., Case No. 18-20185,...more

Seyfarth Shaw LLP

ARB: No Protected Activity where Employee Inadvertently Informed Employer and Only “Hinted” at Filing Whistleblower Complaint

Seyfarth Shaw LLP on

Seyfarth Synopsis: The DOL’s ARB rejected an employee’s SOX retaliation claim where he inadvertently provided information to his employer and only “hinted” that he was filing a SOX-protected complaint. The ARB seems unwilling...more

Polsinelli

New Settlement Program for Medicare Overpayments

Polsinelli on

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

Arnall Golden Gregory LLP

Tracking the Docket for Challenges to Medicare Post-Payment Review

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

Cozen O'Connor

Federal Court Enjoins Medicare Recoupment

Cozen O'Connor on

A Houston federal judge preliminarily enjoined the government from recouping alleged Medicare overpayments made to an ambulance service company facing bankruptcy. See Adams EMS, Inc. v. Azar, No. H-18-1443, 2018 BL 391263...more

Bass, Berry & Sims PLC

Judicial Opinions Support Delay of Recoupment from Audit Appeals Until After ALJ Hearings in Certain Circumstances

Bass, Berry & Sims PLC on

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

K&L Gates LLP

K&L Gates Triage: Medicare Overpayment Recoupment Halted by Court

K&L Gates LLP on

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

Nelson Mullins Riley & Scarborough LLP

Fifth Circuit Reverses Dismissal of Complaint Seeking Injunction to Prevent Medicare Recoupment Prior to Conclusion of...

On March 27, 2018, the Fifth Circuit Court of Appeals in Family Rehabilitation, Inc. v. Alex Azar, II, Sec. U.S. Dept. of Health & Human Services, No. 17-11337, 2018 WL 1478052, at *1 (5th Cir. Mar. 27, 2018), reversed the...more

Foley & Lardner LLP

CMS Recoupment Efforts Stopped by Court While Overpayment Appeals Are Pending

Foley & Lardner LLP on

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

Jones Day

Texas Federal District Court Prevents Withholding of Medicare Payments

Jones Day on

In a much-anticipated decision in Family Rehab., Inc. v. Azar, Federal Judge Kinkeade enjoined the Centers for Medicare & Medicaid Services ("CMS") from withholding Medicare payments to effectuate the recoupment of the...more

King & Spalding

District Court Enjoins CMS from Recouping a Home Health Agency’s Alleged Overpayments Before the ALJ Hearing

King & Spalding on

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

Burr & Forman

Appealing A South Carolina State Tax Case: Payment Or Bond?

Burr & Forman on

Taxpayers who disagree with a proposed tax assessment issued by the South Carolina Department of Revenue (SCDOR or DOR) may or may not be able reach an agreement at the administrative level. When taxpayers and SCDOR cannot...more

Sheppard Mullin Richter & Hampton LLP

CMS Rolls Out Provider Appeals Settlement Efforts

This year CMS is rolling out two new programs aimed, finally, at helping to settle certain types of pending provider reimbursement appeals. The programs are the Low Volume Appeals Initiative and Settlement Conference...more

Mintz - Health Care Viewpoints

Fifth Circuit Decision is Rare Victory Permitting District Court to Enjoin Recoupment Before Provider Exhausts Administrative...

The all-too-common story of a healthcare company declaring bankruptcy in the face of aggressive Medicare recoupment actions before the company even has a hearing before an Administrative Law Judge (ALJ) may get a new ending –...more

Jones Day

Fifth Circuit Provides Relief for Providers Facing Medicare Appeal Backlogs

Jones Day on

The U.S. Court of Appeals for the Fifth Circuit has provided some relief to health care providers seeking to stop Medicare from "recouping" alleged overpayments before the provider can obtain a hearing before an...more

Baker Donelson

Court Finds Jurisdiction to Bar Recoupment Associated with Pending Claims Appeal

Baker Donelson on

On March 27, 2018, the United States Court of Appeals for the Fifth Circuit published an opinion that provides Family Rehabilitation, Inc. (Family Rehab) a second chance to postpone recoupment of about $7.6 million in...more

Akerman LLP - Health Law Rx

Courts May Now Stop Medicare from Recouping Payments

In recent years, many Medicare providers who have received significant overpayment determinations from Medicare contractors have gone out of business while waiting to be heard before an Administrative Law Judge (ALJ) for a...more

Robinson+Cole Health Law Diagnosis

Fifth Circuit Reinstates Provider’s Collateral Challenge to the Medicare Appeal Process

On March 27, 2018, the United States Court of Appeals for the Fifth Circuit held that a health care provider can seek an injunction in federal court against recoupment by Medicare of alleged overpayments despite not...more

Polsinelli

3 Takeaways from the Recent Ruling on Statistical Extrapolations in CMS Audits

Polsinelli on

On Jan. 20, 2016, a federal district court in the Western District of Texas affirmed a decision of the Medical Appeals Council (Appeals Council) affirming a CMS contractor’s extrapolation methodology used to assess an...more

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Updated: Dec 28, 2021:

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Privacy Officer
JD Supra, LLC
150 Harbor Drive, #2760
Sausalito, CA 94965

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Privacy Officer
JD Supra, LLC
150 Harbor Drive, #2760
Sausalito, CA 94965

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