CMS Announces New and Expanded Appeal Settlement Initiatives

On Friday, November 3, 2017 CMS announced that it will make available a new settlement option for eligible providers and suppliers with a low volume of Medicare Part A and B claim appeals pending at OMHA and/or the Medicare Appeals Council. CMS also announced that OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA option. Low Volume Appeals The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and […]

American Hospital Association Calls on CMS to Address ‘flaws and inaccuracies’ in OIG Audits

In a letter dated October 2nd, the American Hospital Association has called on CMS to take a more active role regarding hospital compliance reviews conducted by the Office of Inspector General (OIG). Citing fundamental flaws and inaccuracies, both in the OIG’s understanding and application of Medicare payment rules and in the procedures used to conduct the audits, the AHA asserts that the flaws “result in vastly overstated repayment demands, unwarranted reputational harm, and diversion of hospital and physician leaders’ time from their core mission of caring for patients.” The AHA further asserts that the OIG’s mistaken legal interpretations result in uneven application of Medicare payment rules and that there is […]

CMS proposes removing total knee replacements from inpatient-only list

In the 2018 OPPS proposed rule, CMS is moving ahead with a proposal to remove total knee replacements under CPT code 27477 (arthroplasty, knee, condyle and plateau; medial and lateral components with or without patella resurfacing (total knee arthroplasty)) from the inpatient-only list. If finalized, the procedure would be added to comprehensive APC (C-APC) 5115 (Level 5 Musculoskeletal Procedures) and assigned status indicator J1 (hospital Part B services paid through a C-APC). The agency solicited comments from the public on whether total knee arthroplasty (TKA) should be removed from the inpatient only list in the 2017 OPPS proposed rule. In making the decision to officially propose removal of TKA from […]

“Grace Period” Coverage Under Exchange Plans: How Federal Regulations Can Alter Eligibility Determinations for Providers

By Matthew Horton, Fotheringill & Wade, LLC The Affordable Care Act (ACA, or commonly referred to as Obamacare) altered the landscape for individual and small group insurance plans. ACA altered this market with two important provisions: (1) the creation of Qualified Health Plans (QHPs, also referred to as Exchange Plans) and (2) establishing Exchanges (also called health care marketplaces), such as the Federal Exchange, Healthcare.gov. With the creation of QHPs under the ACA, there are a litany of new federal requirements health insurers must follow; one such requirement is the “grace period,” and providers should be aware if a patient is in the grace period because of the potential for […]

CMS Issues Proposed Updates to the “Two-Midnight” Rule

On July 1, 2015, CMS released proposed updates to the “Two-Midnight” rule regarding when inpatient admissions are appropriate for payment under Medicare Part A.  The proposed updates were included in the calendar year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) proposed rule.  As per the fact sheet, CMS is: Proposing to change the standard by which inpatient admissions generally qualify for Part A payment based on feedback from hospitals and physician to reiterate and emphasize the role of physician judgment Announcing a change in the enforcement of the standard so that Quality Improvement Organizations (QIOs) will oversee the majority of patient status audits, with the Recovery Audit program focusing […]