News & Analysis as of

Recovery Audit Contractors (RACs)

As Medicare Audit Season Approaches, an Update on the Appeals Backlog

The federal government recently awarded new contracts for Medicare recovery audits, and recovery audit contractors (“RACs”) will start showing up at hospitals, home health providers, and other facilities any time. But this...more

CMS To Expand Use of TPE Audits Nationwide by End of 2017

by Dorsey & Whitney LLP on

Perhaps lost amid the healthcare news coverage of competing proposals regarding “Medicare for All” and the repeal of Obamacare, the Centers for Medicare & Medicaid Services (“CMS”) last month announced the expansion of its...more

CMS Issues Guidance to Change Medical Reviewer Requirements for Complex Medical Reviews

Effective September 12, 2017, the Centers for Medicare & Medicaid Services (CMS) will implement changes to ensure that complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists, or...more

Hospitals and Others Respond to “Red Tape Relief Project” Requests

Last week, a number of health care industry associations sent letters to Congress detailing ways in which the government could relieve them of the burdens associated with “red tape.” The letters are in response to the first...more

“Should Auld Acquaintance Be Forgot” - Performant to Initiate Home Health, Hospice, and DME Audits in 2017

The final quarter of 2016 ended with the Centers for Medicare & Medicaid Services (CMS) announcing Performant Recovery, Inc. (Performant) as the new national Recovery Audit Contractor (RAC) to focus solely on Home Health,...more

Health Care Institutions

by K&L Gates LLP on

Originally published in Haig, Business and Commercial Litigation in Federal Courts, Fourth Edition §§ 87:1 et seq. © 2016 American Bar Association. This chapter discusses federal court litigation relating to health care...more

HHS Says Claims Appeals Backlog Is Decreasing and May Be Eliminated by the End of FY 2019

by King & Spalding on

On November 7, 2016, in the pending American Hospital Association (AHA) v. Burwell litigation, HHS filed a motion for summary judgment. A central focus of HHS’s motion for summary judgment is assertions that “the backlog is...more

Also In The News - Health Headlines - November 2016

by King & Spalding on

CMS Names Latest Round of RAC Contracts – On October 31, 2016, CMS announced it awarded contracts for its Medicare Fee-for-Service Recovery Audit Contractors (RAC) to Performant Recovery, Inc. (Region 1), Cotiviti, LLC...more

CMS to Cut Medical Review Audits for Certain Advanced Alternative Payment Model Participants

by Reed Smith on

In order to improve “clinician engagement” and minimize administrative burdens, CMS has announced an 18-month pilot program to reduce medical review audits for participants in selected Advanced Alternative Payment Models...more

CMS Lifts Temporary Suspension of Short Stay Reviews

by Poyner Spruill LLP on

Effective September 12, 2016, Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) resumed their hospital initial patient status reviews. The purpose of these reviews is to determine the...more

A Favorable, New Climate for Challenging Medicare Appeals

by 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

GAO Report Finds Medicare Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data

by King & Spalding on

On May 13, 2016, the U.S. Government Accountability Office (“GAO”) released a report on the review activities of the different Medicare claim review contractors that CMS uses to help reduce improper payments and protect the...more

And You Thought RAC Audits Couldn’t Get Any Worse

by Faegre Baker Daniels on

If there’s one thing that unites the hospital industry—even the fiercest competitors—it’s hatred of audits by recovery audit contractors, or RACs. Why? For one thing, because RACs operate on a contingency fee basis. They...more

CMS Announces Risk-Based Adjusted Additional Documentation Request Limits for Institutional Providers

by King & Spalding on

On May 3, 2016, CMS announced the availability of a revised method to calculate additional documentation request (ADR) limits for Institutional Providers in the Recovery Audit Contractor (RAC) Program. Under the new method,...more

I’ll Gladly Pay You 10 Years From Today for Care Already Provided

by BakerHostetler on

Most providers whose claims have been determined to be improper by the Recovery Audit Contractors (RACs) under the Medicare Recovery Audit Program have discovered that the appeals backlog “is incontrovertibly grotesque.”...more

President Obama’s Proposed Fiscal Year 2017 Budget Would Establish Competitive Bidding in Medicare Advantage Plans, Reduce...

by King & Spalding on

On February 9, 2016 the Obama administration released its proposed fiscal year (FY) 2017 budget. The budget, which would top $4 trillion, allocates nearly $1 trillion to CMS. This is an increase of $26 billion from the FY...more

HHS May Be Forced to Meet Statutory Deadlines for ALJ Appeals

by King & Spalding on

On February 9, 2016, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit reversed a district court’s dismissal for lack of jurisdiction in the American Hospital Association v. Burwell case. ...more

Health Care Update - February 2016 #4

What to Expect from Congress this Work Period - The next Hill work period basically runs from February 22nd to March 23rd. As Congress returns, here’s a brief look at the pending health care issues on the radar for this...more

Proposed 2017 Budget Savings Proposals Would Impact Providers - But Recent, Significant Decision on RACs May Soon Put Funds Back...

by Bryan Cave on

While providers would certainly feel the pinch from the FY 2017 budget request submitted by President Barack Obama, hospitals have some new hope on receiving funds tied up in the Recovery Audit Contractor (RAC) appeals...more

Judicial Solution May Force Faster Medicare Appeals

by Williams Mullen on

Last week, the American Hospital Association (AHA) and several hospitals were successful in convincing the U.S. Court of Appeals for the D.C. Circuit to overturn a 2014 lower court decision, possibly paving the way for a...more

Preview of Medicare Advantage and Part D Advance Notice and Call Letter: CMS Likely to Address Risk Adjustment, Provider Network,...

by McDermott Will & Emery on

The federal government will soon kick off the all-important annual sub-regulatory cycle for the Medicare Advantage (MA) and Part D programs, issuing proposed policy changes and payment rates for calendar year (CY) 2017. The...more

Senate Considering Bill to Speed Medicare Claims Appeals

by Baker Ober Health Law on

In early December of last year, Orrin Hatch (Senate Finance Committee Chairman, R-UT) and Ron Wyden (D-OR) introduced the Audit and Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 (AFFIRM Act). The purpose of...more

CMS Proposes Expansion of RAC Program to Medicare Part C – All Medicare Advantage Contracts to Become Target of RADV Audits

On December 22, 2015, the Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI) and a proposed statement of work (SOW) seeking industry feedback on the expansion of the recovery audit...more

Medicare Proposes to Increase RAC Use

by Foley & Lardner LLP on

By now, providers are very familiar with Medicare recovery audit contractors, or RACs – the private companies who have authority to review medical records at a moment’s notice. For every dollar they opine has been improperly...more

CMS Preparing to Launch RACs for Medicare Advantage

by King & Spalding on

On December 22, 2015, CMS issued a Request for Information (RFI) detailing plans to expand its Recovery Audit Contractor (RAC) program to cover Medicare Advantage organizations. ...more

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