News & Analysis as of

Administrative Law Judge (ALJ) Appeals Centers for Medicare & Medicaid Services (CMS)

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

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

Mintz - Health Care Viewpoints

HHS Announces a “Settlement Express” Option for Medicare Appeals

HHS’s Office of Medicare Hearings and Appeals (OMHA) has long faced a backlog in Medicare appeals to Administrative Law Judges (ALJs). In an effort to address this backlog, OMHA established a Settlement Conference...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

Arnall Golden Gregory LLP

CMS Announces Low Volume Appeal Settlement Option for Providers Mired in ALJ Backlog

On January 9, 2018, the Centers for Medicare and Medicaid Services (CMS) announced details on the new low volume appeal settlement option, which is the latest alternative available to Medicare Part A and Part B providers and...more

Faegre Drinker Biddle & Reath LLP

Medicare Appeal Proposal Falls Far Short of Court Mandate

For years the hospital industry has been in an uproar over the mountainous backlog of Medicare claim appeals. Current estimates are that a whopping 650,000 claims are at the Administrative Law Judge level awaiting...more

Latham & Watkins LLP

A Favorable, New Climate for Challenging Medicare Appeals

Latham & Watkins LLP on

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

Polsinelli

OMHA Expands Settlement Conference Facilitation Program to Part A Appeals: 10 Things to Know

Polsinelli on

On Feb. 25, 2016, the Office of Medicare Hearings and Appeals (OMHA) conducted a teleconference to address Phase III of the Settlement Conference Facilitation (SCF) project, which also became effective on Feb. 25, 2016. SCF,...more

Polsinelli

Four Key Takeaways on the Expansion of the Medicare Appeals Settlement Conference Project

Polsinelli on

On October 15, 2015, the Office of Medicare Hearings and Appeals (“OMHA”) conducted a teleconference to address Phase II of the Settlement Conference Facilitation (“SCF”) Pilot, effective October 1, 2015. SCF, launched in...more

Baker Donelson

Only One Short Bite of the Apple: Change in the Medicare Enrollment Appeals Process

Baker Donelson on

In keeping with the trend to strengthen its authority to deny an enrollment or revoke Medicare billing privileges, CMS has modified the appeals process in a manner that will significantly shorten the time allotted to mount an...more

Arnall Golden Gregory LLP

CMS Limits the Scope of Review for Certain Redeterminations and Reconsiderations

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

Polsinelli

Senate Committee Passes Bill Addressing Medicare Appeals Inefficiencies

Polsinelli on

On June 3, 2015, the Senate Finance Committee passed an original bill that aims to streamline and improve the Medicare Audit and Appeals Process. The Medicare appeals process has recently faced scrutiny from industry leaders...more

Baker Donelson

CMS Instructs MACs to Participate in ALJ Hearings

Baker Donelson on

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

King & Spalding

OMHA Announces Two New Programs to Address Appeals Backlog

King & Spalding on

The Office of Medicare Hearings and Appeals (OMHA), which oversees the Administrative Law Judge (ALJ) level of appeal, recently posted two important announcements regarding a new Statistical Sampling Initiative (SSI) and...more

Baker Donelson

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

Baker Donelson on

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

BakerHostetler

ALJ Appeals Frequently Favorable To Providers; OIG Calls For Reforms

BakerHostetler on

The OIG recently published a report reviewing the implementation of 2005 regulations regarding the administrative law judge (ALJ) level of appeals, the third level of the Medicare appeals system. The 2005 regulatory changes...more

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