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Hospitals Inpatient Billing

King & Spalding

OIG Audit Finds Medicare Overpaid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation

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On August 12, 2024, OIG announced the results of an audit of payments made to hospitals for inpatient claims with the Medicare Severity Diagnosis-Related Groups (MS-DRGs) that require ninety-six hours of consecutive...more

Brownstein Hyatt Farber Schreck

CMS Releases Annual Medicare Hospital OPPS and ASC Payment System Proposed Rule

On July 10, the Centers for Medicare and Medicaid Services (CMS) released its annual Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule, which provides...more

King & Spalding

OIG Report Details Weaknesses in Enforcement of Two-Midnight Rule

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CMS estimates that between 2017 and 2021, Medicare Part A improperly paid $23.9 billion for inpatient hospital stays, with $7.8 billion attributable to short stays that did not qualify for Medicare Part A. On June 13, 2024,...more

Harris Beach PLLC

OIG Approves MediGap Insurer’s Use of PHO Network Hospitals to Offer Discounts on Inpatient Deductibles

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The Office of Inspector General (OIG) recently issued two identical favorable OIG Advisory Opinions, concluding that, although the proposed arrangement (“Proposed Arrangement”) between a Medicare Supplement insurer (“MediGap...more

Holland & Knight LLP

CMS Releases CY 2022 OPPS and ASC Proposed Rule

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The Centers for Medicare & Medicaid Services (CMS) on July 19, 2021, released its calendar year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed...more

Epstein Becker & Green

New York State Department of Financial Services Summarizes Changes Relating to Administrative Denials, Prior Authorizations, and...

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On March 10, 2021, the New York State Department of Financial Services (“DFS”) issued Insurance Circular Letter No. 4 (“Circular Letter”), which both explains modifications to the Insurance Law and the Public Health Law...more

Health Care Compliance Association (HCCA)

CMS offers correct billing tips for nonphysician outpatient services provided before or during inpatient stays

Compliance Today (March 2021) - The Centers for Medicare & Medicaid Services (CMS) has provided the following compliance notice: “In a recent report, the Office of Inspector General (OIG) determined that Medicare made...more

Benesch

Dialysis & Nephrology Digest - March 2021

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Fresenius to defend itself from FCA suit following whistleblower allegations - A former employee alleges Fresenius engaged in arrangements with hospitals and nephrologists to ensure patient referrals to its dialysis...more

Hogan Lovells

FCA Alert: Decision Opens Door to Challenge of Agency Guidance in False Claims Cases

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On November 5, 2019, the United States District Court for the Eastern District of Pennsylvania ruled on a motion to dismiss a False Claims Act (FCA) qui tam suit filed by the United States Department of Justice, long after it...more

Health Care Compliance Association (HCCA)

CMS Rules: Direct Supervision Is Gone, Prior Auth Is Here; Documentation Fix Has Limits

Report on Medicare Compliance 28, no. 40 (November 11, 2019) - CMS has given the green light to prior authorization for five types of procedures in an attempt to control “unnecessary increases” in these procedures as part...more

King & Spalding

How Payers Are Improperly Underpaying Inpatient Services As Observation Services

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Health plans and their delegated IPAs are using a number of different tactics to deny payment for inpatient services by improperly classifying inpatient claims as observation or other types of outpatient status. Payers are...more

King & Spalding

Florida Hospitals Prevail in Litigation Challenging the Exclusion of Low Income Pool Days from the Medicare Disproportionate Share...

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On July 23, 2019, Judge Rosemary Collyer of the United States District Court for the District of Columbia issued an opinion ruling in favor of ten Florida hospitals in their case challenging the calculation of their Medicare...more

King & Spalding

CMS Issues Proposed Rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System

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The display copy of the proposed rulemaking for the FY 2020 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) was posted on the Federal Register website last week (the Proposed Rule). The IPF PPS pays...more

Mintz - Health Care Viewpoints

Surprise Medical Bills Gain National Attention

No one wants to be faced with a large, unexpected medical bill after receiving health care services. Unfortunately, patients often find themselves in this situation after seeking emergency treatment or transportation,...more

King & Spalding

OIG Hospital Compliance Program Audit Claims $22 Million in Extrapolated Overpayments

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A recent report issued by OIG finding an Indiana community hospital owed over $22 million in extrapolated overpayments carries some important lessons for hospitals audited under OIG’s hospital compliance program. As described...more

Robinson+Cole Health Law Diagnosis

CMS Revises Hospital Inpatient Admission Order Documentation Requirements

On August 17, 2018, the Centers for Medicare & Medicaid Services (CMS) published its Hospital Inpatient Prospective Payment Systems final rule for Fiscal Year 2019 (Final Rule). The Final Rule contains a number of important...more

Baker Donelson

CMS Softens Physician Inpatient Order Documentation Requirement

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Effective for hospital inpatient admissions on or after October 1, 2018, CMS has removed the requirement that a signed physician order must be present in the medical record to establish inpatient coverage. While this guidance...more

King & Spalding

Texas Health System Pays Nearly $2 Million To Settle Allegations of Improper Billing for Inpatient Services

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On May 14, 2018, the U.S. Attorney’s Office for the Southern District of Texas announced that Memorial Hermann Health System (MHHS) will pay $1,929,071.38 to resolve allegations that it improperly billed government healthcare...more

Robinson+Cole Health Law Diagnosis

CMS Releases 2018 OPPS/ASC Payment Systems Final Rule

The Centers for Medicare and Medicaid Services (CMS) issued the 2018 Medicare: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule with comment...more

Baker Donelson

Will CMS Consider Your Institution to Be a Hospital? Guidance on the "Primarily Engaged In" Standard

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Recent guidance from CMS suggests that some hospitals, and particularly specialty hospitals that provide mostly outpatient care, may soon find themselves the focus of surveyors' scrutiny. In early September, CMS issued...more

Baker Donelson

OIG Finds Acute Care Hospitals Improperly Billed for Outpatient Services Provided to Inpatients of Other Hospitals

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Acute care hospitals that provide Medicare outpatient services to inpatients of other hospitals should be billing and collecting payment from the other inpatient hospitals and not from Medicare....more

Polsinelli

Hospital Medicare Certification at Risk? CMS Clarifies Inpatient Volume Expectations

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Hospitals with dangerously low inpatient volume and micro hospitals focused primarily on the delivery of outpatient and/or emergency room services instead of inpatient services beware: CMS (Centers for Medicare and Medicaid...more

Bradley Arant Boult Cummings LLP

What Exactly Is a Hospital, Anyway? CMS Issues Guidance on “Primarily Engaged” Medicare Certification Requirement

The rules that govern participation in the Medicare program are notoriously voluminous and complex. Indeed, courts have described them as akin to a “[body of] law written by James Joyce and edited by E.E. Cummings” and “among...more

Polsinelli

Five Things to Know About CMS's Second Round of Settlements for Hospital Appeals

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The Centers for Medicare and Medicaid Services (CMS) announced that beginning December 1, 2016, it is offering to settle certain inpatient-status claims to eligible hospitals willing to withdraw from the administrative...more

King & Spalding

OIG Recommends Eliminating Provider-Based Designation for Facilities Owned by Hospitals

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In a report released on June 17, 2016, OIG renewed its call for CMS to either eliminate the provider-based designation, which allows facilities owned by and integrated with a hospital to bill Medicare as a hospital outpatient...more

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