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
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
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 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
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
CMS issued a special edition MLN Matters meant to be effective August 1, 2015. The guidance reflects CMS instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the...more
CMS recently issued Transmittal 543, Change Request 8501 in which it instructs Medicare Administrative Contractors (MACs) to, among other things, defend their medical review decisions through the Administrative Law Judge...more