News & Analysis as of

Overpayment Appeals

Hendershot Cowart P.C.

CMS, Qlarant Scrutinizing Medicare Claims for Skin Substitute Treatments

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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

Bass, Berry & Sims PLC

Second Circuit Holds False Claims Act Complaint Is Barred by SEC Filings

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In July 2021, the U.S. District Court for the Eastern District of New York dismissed a False Claims Act complaint filed by CKD Project, LLC, an entity created for the purpose of filing the lawsuit, which alleged that...more

Oberheiden P.C.

10 Keys to a Successful Pharmacy Audit Appeal

Oberheiden P.C. on

Medicare, Medicaid, and pharmacy benefit manager (PBM) audits can result in substantial losses for pharmacies. If auditors uncover evidence—or apparent evidence—of overpayments, not only can they initiate recoupments, but...more

King & Spalding

Fifth Circuit Holds District Court Has Jurisdiction to Decide Repayment Amount Owed by HHS to Medicare Provider as an...

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On January 3, 2022, the U.S. Court of Appeals for the Fifth Circuit Court reversed the decision of the District Court for the Western District of Louisiana dismissing for lack of jurisdiction a Medicare provider’s suit...more

King & Spalding

Seventh Circuit Upholds Dismissal of Medicare Overpayment Lawsuit Brought by Home Health Agency for Failing to Complete...

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On June 3, 2021, the Seventh Circuit upheld a decision by the U.S. District Court of the Northern District of Illinois to dismiss a home health agency’s lawsuit against a Medicare integrity contractor for temporarily...more

King & Spalding

Home Health Agency Unable to Block HHS From Recouping $2.8 Million in Alleged Overpayments

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An Arizona District Court judge held last week that the court lacked subject-matter jurisdiction over a home health agency’s (HHA) procedural due process claim because the HHA had failed to present its claim to HHS first and...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

Arnall Golden Gregory LLP

OIG Weighs-In on the Review of Extrapolated Overpayments in the Medicare Appeals Process

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

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

McDermott Will & Emery

Second Circuit Weighs in on Tax Court’s Refund Jurisdiction

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Borenstein v. Commissioner is an interesting opinion involving the intersection of canons of statutory construction and jurisdiction. Recently, the US Court of Appeals for the Second Circuit reversed the US Tax Court’s...more

Eversheds Sutherland (US) LLP

The Second Circuit - canons of construction prevail in dizzying case of “black hole” tax refunds

In an important win for taxpayers, a unanimous Second Circuit reversed the Tax Court on a statutory interpretation issue involving the three-year “look-back” period for Tax Court jurisdiction over refunds. Borenstein v....more

Baker Donelson

New Medicaid DSH Audit Guidance: Its Impact on Pending and Recent State DSH Audits

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On December 31, 2018, the Center for Medicaid and CHIP Services issued a notice indicating that CMS was altering its prior audit guidance for Medicaid Disproportionate Share Hospital (DSH) audits that had previously been...more

Jones Day

D.C. District Court Vacates 60-Day Medicare Advantage Overpayment Rule

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The Situation: In 2016, several Medicare Advantage ("MA") organizations challenged a 2014 final rule promulgated by the Center for Medicare Services ("CMS") that broadly subjected MA organizations to potential liability under...more

K&L Gates LLP

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

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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

Burr & Forman

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

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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

Baker Donelson

Court Finds Jurisdiction to Bar Recoupment Associated with Pending Claims Appeal

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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

Bradley Arant Boult Cummings LLP

False Claims Act: 2016 Year in Review

We are pleased to present Bradley’s annual review of significant False Claims Act (FCA) cases, developments, and trends. From a relatively short article several years ago, the Review has grown to a significant publication...more

Proskauer - Employee Benefits & Executive...

Pension Consultant Found Not to be an ERISA Fiduciary

The Tenth Circuit held that a pension plan consultant, who misstated the amount of monthly pension payments that a pension plan participant would receive in retirement, was not a fiduciary under ERISA. Plaintiffs Trent...more

King & Spalding

Tenth Circuit Rebukes CMS for Applying Wrong Regulations in Overpayment Action

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The United States Court of Appeals for the Tenth Circuit shot down CMS’s overpayment recoupment related to physical therapy and skilled nursing services, citing multiple errors in CMS’s appeal briefing and concluding that “an...more

Baker Donelson

No Judicial Review of Contractor’s Finding of a High Payment Error Rate, a Condition for Extrapolation

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Before a Medicare contractor can use extrapolation to determine an overpayment amount, the Medicare statute requires that it must make a finding that there is a sustained or high level of payment error or that documented...more

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