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Physician Groups Sue Anthem in Georgia Over ED Policy

In an effort to compel Anthem’s Blue Cross Blue Shield of Georgia to rescind its “controversial and dangerous emergency care policy” that retroactively denies coverage for emergency patients, the American College of Emergency Physicians (ACEP) and Medical Association of Georgia (MAG) have filed suit in the U.S. District Court for the Northern District of Georgia. The policy, implemented by Anthem in Georgia and five other states over the past year, leaves patients who sought emergency care responsible for paying their entire bills if Anthem determines, after retrospective review, that their diagnoses were not truly emergencies. Along with Georgia, the other states include Indiana, Kentucky, Missouri, New Hampshire and Ohio. Continue reading

OMHA Expands Settlement Conference Facilitation (SCF) Program

CMS has announced that the Office of Medicare Hearings and Appeals (OMHA) will be expanding its current Settlement Conference Facilitation (SCF) program to reach additional providers and suppliers. Medicare Part A and Medicare Part B providers and suppliers who have OMHA or Medicare Appeals Council (Council) appeals pending may be eligible to participate in the expanded SCF process. Continue reading

CMS Extends Low Volume Appeals Deadline

The Centers for Medicare & Medicaid Services (CMS) is extending the deadline for appellants to submit an expression of interest (EOI) for the Low Volume Appeals (LVA) Initiative to June 8, 2018.  Appellants with either an odd or an even NPI, that meet the eligibility criteria, should submit an EOI between April 12, 2018 and June 8, 2018.  Details about the process, including a fillable EOI, are available here.

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  The District Court order was rescinded by the Appeals Court in August.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.