AHA Urges Court to Reinstate HHS Deadline to Clear Appeals Backlog

On Thursday, February 15th, the American Hospital Association (AHA) and three member hospitals urged the U.S. District Court for the District of Columbia to reinstate its earlier order requiring the Secretary of Health and Human Services to clear the Medicare appeals backlog at the administrative law judge (ALJ) level within five years.  The District Court order was rescinded by the Appeals Court in August.   In remanding the case, the appeals court left the lower court free to reinstate the same requirement if HHS fails to demonstrate that it is “impossible” to comply with the mandamus order.  In yesterday’s brief the AHA urged the court to do just that.  “Because the Secretary has not shown it is impossible to clear the backlog—minus, perhaps, some claims with serious program-integrity concerns—within five years, the Court should require him to do so.” Continue reading

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. Read the full post here.

CMS To Expand Targeted Probe and Education Program

Citing a decrease in appealed claim decisions and an increase in the acceptance of provider education under the pilot program, CMS has announced that they have decided to expand the Targeted Probe and Educate (TPE) program to all MAC jurisdictions in latter part of 2017. The TPE program grew out of the broad Probe and Educate program initiated by CMS in 2014. The TPE program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017. Continue reading

Appeals Court Overturns Ruling Requiring HHS to Clear Medicare Appeals Backlog By 2021

On Friday, the U.S. Appeals Court for the District of Columbia overturned an order requiring Department of Health and Human Services (HHS) to clear its backlog of Medicare reimbursement appeals by the end of 2020. Indicating that the district court “declined to seriously grapple with the Secretary’s assertion that lawful compliance with such a mandamus order would be impossible,” the appellate court ruled that it was an “error or law” and an “abuse of discretion” for the district court to order the Secretary to perform an act – clear the backlog by certain deadlines – without evaluating whether performance was possible. Continue reading

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).

Read our full post here.