Is the Department of Health and Human Services (HHS or the government) required to engage in notice and comment rulemaking when it changes a requirement that has an important impact on hospitals' reimbursement? As we reported...more
10/11/2018
/ Administrative Procedure Act ,
Appeals ,
Azar v Allina Health Services ,
Centers for Medicare & Medicaid Services (CMS) ,
Certiorari ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
Health Care Providers ,
Hospitals ,
Interpretive Rule ,
Medicare ,
Medicare Part C ,
Notice and Comment ,
Petition for Writ of Certiorari ,
Physician Medicare Reimbursements ,
Provider Payments ,
Rulemaking Process ,
SCOTUS
In a decision with implications that could go back 35 years, the United States Court of Appeals for the District of Columbia Circuit rejected a CMS interpretation of its reopening rules as that interpretation affects current...more
In Northeast Hosp. Corp. v Sebelius, 657 F.3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit upheld hospitals' challenge to CMS's disproportionate share hospital (DSH) calculation...more
7/16/2018
/ Administrative Appeals ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Inpatient Prospective Payment System (IPPS) ,
Judicial Review ,
Medicaid ,
Medicare ,
Provider Payments ,
Reviewability Determinations ,
Statutory Construction Test
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
4/12/2018
/ Administrative Appeals ,
Administrative Backlogs ,
Administrative Law Judge (ALJ) ,
Appeals ,
Dismissals ,
Due Process ,
Exhaustion Doctrine ,
Health Care Providers ,
Judicial Review ,
Medicare ,
Overpayment ,
Preliminary Injunctions ,
Recoupment ,
Reversal ,
Social Security Act ,
Subject Matter Jurisdiction ,
TRO ,
Ultra Vires
On December 26, 2017, the United States Court of Appeals for the District of Columbia Circuit upheld the procedural validity of 2010 manual instructions setting out the criteria by which Medicare outlier payments might be...more
For much of the past decade, hospitals and CMS have battled over whether providers may claim, as Medicare reasonable costs, the full amount of provider tax assessments levied upon them by the states in which they operate. In...more
1/17/2018
/ Appeals ,
Arbitrary and Capricious ,
Centers for Medicare & Medicaid Services (CMS) ,
Health Care Providers ,
Hospitals ,
Medicaid ,
Medicare ,
Medicare Taxes ,
Physician Medicare Reimbursements ,
Provider Reimbursement Manual ,
Provider Reimbursement Review Board ,
Refunds ,
Reversal
Hospitals affected by HHS's 2014 decision to include Medicare Part C enrollees as part of the Medicare fraction of the disproportionate share calculation obtained relief late last month when that position was voided by the...more
8/28/2017
/ Administrative Procedure Act ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Medicare ,
Medicare Part C ,
Notice and Comment ,
Provider Payments ,
Retroactive Application ,
Reversal
On July 26, 2016, the United States Court of Appeals for the District of Columbia Circuit decided Fla. Health Sciences Ctr. v. Burwell. In that case, the Court analyzed a statutory bar against judicial review of estimates...more
10/5/2016
/ Administrative Procedure Act ,
Administrative Review ,
Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Disproportionate Share Adjustments ,
DSH Adjustments ,
Hospitals ,
Judicial Review ,
Medicaid ,
Medicare ,
Non-Appealable Decisions ,
Provider Payments ,
Reviewability Determinations
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 25, 2016, entitled, Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and...more
8/10/2016
/ ACOs ,
Alternative Payment Models (APM) ,
Appeals ,
BPCI ,
Centers for Medicare & Medicaid Services (CMS) ,
Collaboration ,
Episode Payment Models (EPM) ,
Fraud and Abuse ,
Gainsharing ,
Hospitals ,
Incentive Compensation ,
Medicare ,
Medicare Access and CHIP Reauthorization (MACRA) ,
Medicare Shared Savings Program ,
MIPS ,
Physicians ,
Proposed Rules ,
Public Comment ,
Telehealth ,
Waivers
In a detailed opinion that likely constitutes the last word on the matter, the Eleventh Circuit recently held in Fla. Agency for Health Care Administration v. Bayou Shores SNF, LLC that bankruptcy courts lack jurisdiction...more
On December 29, 2015 the U.S. Court of Appeals for the District of Columbia rejected a challenge to a psychiatric hospital's pre-PPS Medicare reimbursement. Washington Regional Medicorp v. Burwell, No. 1:13-cv-00622 (D.C....more
As part of the Outpatient Prospective Payment System (OPPS) final rule published in the Federal Register on November 13, 2015, CMS made noteworthy changes to the Medicare cost report and appeal rules. See 80 Fed. Reg. 70298...more
As we reported in an earlier Payment Matters article, the United States Court of Appeals for the District of Columbia Circuit handed hospitals a partial victory on May 19, 2015, in their challenge to Medicare outlier payments...more
In a decision handed down on August 7, 2015, the United States Court of Appeals for the District of Columbia Circuit upheld the denial of the providers' bad debt claims associated with dual eligible beneficiaries. Grossmont...more
9/5/2015
/ Appeals ,
Bad Debt ,
Centers for Medicare & Medicaid Services (CMS) ,
Co-Insurance Payments ,
Deductibles ,
Dual Beneficiaries ,
Filing Deadlines ,
Hospitals ,
Medi-Cal ,
Medicaid ,
Medicare ,
Provider Reimbursement Manual
As we reported in previous Payment Matters articles, the United States District Court for the District of Columbia has issued inconsistent opinions regarding Medicare's policy not to allow bad debt when that bad debt is still...more
Under the Medicare statute and implementing regulation, providers have 180 days from the issuance of a Notice of Program Reimbursement (NPR) in which to file an appeal to the Provider Reimbursement Review Board (PRRB). This...more
In recent times, the provider community has enjoyed success in challenging the Secretary’s interpretation of the Medicare disproportionate share hospital (DSH) adjustment provisions and what, the providers have maintained,...more
In a 2011 decision, Northeast Hospital Corp. v. Sebelius, 657 F. 3d 1 (D.C. Cir. 2011), the United States Court of Appeals for the District of Columbia Circuit ruled for the providers in a challenge to the Secretary’s...more