Gracielinda Prescott | July 27, 2016

CMS Proposed Rule to Implement Major Reforms to Medicare Appeals Process

Andrew B. Wachler, Esq. Jessica C. Forster, Esq. On July 5, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule heralding significant changes to the Medicare appeals process, particularly in light of the backlog of Medicare appeals currently pending. Recently, this backlog has been the subject of focus for the U.S. Department of Health and Human Services (HHS), CMS, the Government Accountability Office (GAO), and Congress. These government entities …

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Steven Greenspan, JD, LLM | July 27, 2016

Proposed Rule Yields New Power to DAB

Last month the U.S. Department of Health and Human Services (HHS) issued a notice of proposed rulemaking known as HHS 2015-49. This proposed rule revises the procedures that HHS follows at the administrative law judge (ALJ) level of appeal and also revises the procedures that HHS follows at the lower levels of appeal – including the Departmental Appeals Board (DAB) level. This article discusses one of the proposed changes in particular: the …

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Edward M. Roche, PhD, JD | July 27, 2016

EXCLUSIVE: Medicare Appeals System is Broken – And it Might not be Fixable

In 2010, there were 41,733 Medicare appeals filed with administrative law judges (ALJs). By 2015, the number had increased to 432,534, a jump of 936 percent. The number of ALJs handling this appeals load has remained more or less constant at 77.   In 2010, the ALJ system (Level 3 appeals) already was showing symptoms of being overloaded. More than one-third (36.7 percent) of ALJ decisions were being turned in late, …

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07.20.2016
68-Percent Settlement Focus of Upcoming Town Hall Broadcast
68-Percent Settlement Focus of Upcoming Town Hall Broadcast

Andrew Wachler, Esq. Steven Greenspan, JD, LLM With hopes that the Centers for Medicare & Medicaid Services (CMS) might reopen the 68-percent settlement solution it once offered providers to expedite the appeal process, RACmonitor is producing a special-edition broadcast on the topic scheduled to air live at noon ET on Tuesday, Aug. 9.  The 60-minute, live “town hall” broadcast is being sponsored by...

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07.20.2016
HCCs: Higher Scores, Higher Capitation Snags Florida Doctor
HCCs: Higher Scores, Higher Capitation Snags Florida Doctor

Some loyal RACmonitor readers may recall that way back in November of 2014, I wrote a RACmonitor article entitled It’s All About the Money – When is a Doctor Not a Doctor?, about Medicare Advantage (MA) plans contracting with firms to send physicians and non-physician practitioners out to the homes of their enrollees to take a history and perform a...

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07.20.2016
Avoid Hiring Black-and-White Thinking Compliance Professionals
Avoid Hiring Black-and-White Thinking Compliance Professionals

In a recent article, I quoted Dave Mason to illustrate the point that it can be reasonable to question authority. At times, however, people make unreasonable challenges. An irrational employee is not only a huge frustration; they also present a major compliance risk. Many qui tam lawsuits being with an employee who mistakenly believe you are breaking the law but won’t...

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07.20.2016
House Ways and Means Committee Advances Measure to Provide Rural Regulatory Relief
House Ways and Means Committee Advances Measure to Provide Rural Regulatory Relief

Question: How do you spell “rural regulatory relief?" Answer: By providing a permanent extension of the enforcement instruction on unreasonable supervision requirements for outpatient therapeutic services in critical access and small rural hospitals.  In what some are seeing as a wrong being addressed – if not finally righted – and at perhaps one of the most vulnerable times for healthcare in rural...

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OIG

OIG Work Plan: Fair Warning

Chuck Buck | 11.04.2015

OIG Work Plan: Fair Warning

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2016 Work Plan comes with a warning: the OIG continues to be relentless in detecting and...

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Feature Articles

Exclusion: What You Don’t Know Could Hur…

Gracielinda Prescott | 07.27.2016

Exclusion: What You Don’t Know Could Hurt

When you go to a doctor’s office or hospital, you expect that the medical professional who provides care and services is licensed,trained, and in possession of the proper credentials, right?...

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IRF

Nordian Posts Results of Recent Oregon P…

Angela Phillips, PT - avatar Angela Phillips, PT | 05.04.2016

Nordian Posts Results of Recent Oregon Probe Audit:  Once Again, No Surprises for IRFs in the Results

Last month, we discussed Noridian’s findings from the IRF Probe Audit for Arizona conducted from December 21, 2015, through March 3, 2016. At that time, we agreed to provide the...

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