The CMS Interoperability and Prior Authorization Rules
Podcast — Drug Pricing: How Are Payers Responding to the IRA?
Findings from Gibbins’ Annual Healthcare Bankruptcy Report
A Fond Farewell: Musings on the End of the Medicare Advantage Hospice Carve-In Demonstration
Video: Braidwood v. Becerra – Challenging the Affordable Care Act’s Preventive Services Coverage Provision – Thought Leaders in Health Law
Hospice and Home Health Survey Perspectives: A Conversation with Kim Skehan, VP of Accreditation at CHAP
Transparency and the Open Payments Program
Taking the Pulse, A Health Care and Life Sciences Video Podcast | Episode 173: Improving rural health care with Dr. Kevin Bennett, the Director of the Research Center for Transforming Health and the
Counsel That Cares - The Private Payer's Perspective on Value-Based Care
Podcast: Health Equity – Behind the Buzzwords – Diagnosing Health Care
A Very “Special” Episode: Amid Controversy, CMS Launches the Hospice Special Focus Program
Grace from CMS: Unexpected Good News on HIS and CAHPS Appeals
This Bandwagon Has a Broken Wheel: OIG Joins the Inconsistent Approach to Hospice GIP Claims
Behind the Curtain: Enhanced Provider Enrollment Oversight
Survey Woes: CMS Ramps Up Hospice Survey Program and Consequences
Inflation Reduction Act’s Drug Price Negotiation Provisions – What Now? – Diagnosing Health Care Podcast
A Glimpse Into the Other Side: Understanding the Perspective of Government Enforcers
I Understood There Would Be No Math: Audits, Extrapolations, and a New Set of Rules
Podcast: Inflation Reduction Act’s Drug Price Negotiation Provisions – What’s Next? - Diagnosing Health Care
Quick Takeaways From the 2024 Proposed Hospice Wage Index Rule
As an attorney specializing in healthcare reimbursement, I have focused my practice on helping healthcare providers navigate the Center for Medicare and Medicaid (“CMS”) administrative appeal process. I usually get a call...more
On December 16, 2019, a nationwide coalition of hospitals sued HHS to block implementation of the 340B rate cuts contained in the 2020 Hospital Outpatient Prospective Payment System (“OPPS”) Final Rule. As detailed in our...more
Polsinelli is pleased to share the Health Care Reimbursement and Payor Dispute Update. This newsletter is a designated source of news, information and guidance on the constantly evolving reimbursement industry. ...more
In the wake of its recent efforts to settle claims (see the 2014 initial hospital inpatient settlement and the 2016 second-round wave), in the heavily backlogged Medicare administrative appeals system, CMS has introduced a...more
On June 17, 2019, CMS announced a voluntary settlement program for Inpatient Rehabilitation Facility (IRF) appeals pending at the Medicare Administrative Contractor (MAC), the Qualified Independent Contractor, the Office of...more
On May 3, 2019, CMS issued its final rule implementing changes to the appeal procedures for Medicare claims and Medicare prescription drug coverage determinations (the Final Rule). The Final Rule will be published in the...more
CMS recently issued a Medicare Learning Network (MLN) Matters article in connection with Change Request 11042 released on April 12, 2019 (the Change Request), which revises the Medicare Claims Processing Manual (Publication...more
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
In this episode, Gary Qualls discusses a recent development in payer litigation, regarding a provider’s recovery of Medicare Advantage payments pursuant to a Medicare Advantage contract. Specifically, a recent federal case...more
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
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
Last week, the U.S. Court of Appeals for the District of Columbia Circuit invalidated CMS’s prohibition on appeals of so-called predicate facts. The appeal before the court, described in greater detail below, challenged the...more
The Department of Health and Human Services (HHS) announced on November 3, 2017 additional settlement options for providers and suppliers in an effort to improve the Medicare claims appeals process, which included (1) the Low...more
The OIG added three items to its Work Plan with the February 2018 update, as listed in the chart below. Two of the items concern annual reports, one addressing the performance of Medicaid Fraud Control Units and the other...more
On February 5, 2018, the Centers for Medicare and Medicaid Services (“CMS”) began accepting Expressions of Interest (“EOI(s)”) from Medicare fee-for-service providers to participate in a new Low-Volume Appeals Initiative...more
Welcome to the third edition of Williams Mullen On Call. In this edition, we are pleased to provide two very timely interviews. The first interview is with Mandy K. Cohen, MD, MPH, Secretary of the North Carolina Department...more
On August 11, 2017, the D.C. Circuit issued its decision on the District Court’s order in American Hospital Association v. Price in a 2-1 decision, holding that the District Court abused its discretion by ordering the...more
On September 19, 2016, the U.S. District Court for the District of Columbia rejected a request by HHS to stay proceedings in litigation brought by the American Hospital Association and several providers seeking to compel the...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
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
On June 9, 2016, the Government Accountability Office (GAO) publicly released a report published May 10, 2016, regarding the continuing challenges surrounding the backlog of the administrative appeals process for Medicare...more
Last week CMS announced a temporary "pause" in the review of inpatient admissions by the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs). CMS posted this announcement on its Inpatient Hospital...more
Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) should not expand redeterminations and reconsiderations of claims denied on the basis of complex pre–or post–pay payments or automated...more
Proposed rules, touted as enhancing the provider enrollment process, would provide CMS with sanction authority that closely parallels the OIG’s exclusion authority. Under the proposed rules, CMS would have expanded bases to...more