Articles Posted in Recovery Audit Contractors (RACs) and Medicare Appeals

The AHA has taken its first steps to appeal a lower court’s refusal to intervene to address the significant appeals backlog pending at the ALJ level of appeal. On May 4, 2015, the AHA submitted its Opening Brief to the U.S. Court of Appeals for the D.C. Circuit, alleging that the District Court erred in […]

The appeals backlog has taken a toll not only on appellants, but also the Office of Medicare Hearings and Appeals (OMHA), tasked to adjudicate the appeals. The appeals submission and document management processes are overdue for an upgrade in order to keep up with OMHA’s substantial workload. The new system to be put into place […]

On January 22, 2015, in the case of Barrows v. Burwell, No. 3:11-cv-1703, 2015 WL 264727 (2nd Cir., January 22, 2015), the United States Court of Appeals for the Second Circuit ruled that Medicare beneficiaries be granted the opportunity to demonstrate a Constitutionally-protected property interest to challenge their patient status designations as hospital outpatients rather […]

On July 8, 2014, the Office of Medicare Hearings and Appeals (“OMHA”) posted to its website a new sampling pilot initiative to address large volumes of claims pending at the ALJ stage of appeal. The sampling request can be initiated by an appellant, or OMHA may offer an appellant the sampling pilot. To be eligible […]

The landscape of the Medicare appeals process is quickly changing with the launch of the Settlement Conference Facilitation (“SCF”) pilot program. The program is designed to be an alternate dispute resolution process where the appellant and the Centers for Medicare & Medicaid Services (“CMS”) come together to discuss a potential mutually agreeable resolution of claims […]

The Program for Evaluating Payment Patterns Electronic Report (“PEPPER”) is an electronic data report under contract with the Centers for Medicare & Medicaid Services (“CMS”) that helps guide hospital’s auditing and monitoring services. In 2014, PEPPER published new target areas for Short-Term Acute Care hospitals that were identified as prone to improper Medicare payments. Significantly, […]

In December of 2013, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Quotes for new Recovery Auditor (RAC) contracts. The new contracts include significant changes to payment terms. Whereas the current contracts allow payment to RACs after the first level of appeal has been exhausted (120 days), the new contracts do […]

On August 2, 2013, the Centers for Medicare & Medicaid Services (“CMS”) published its highly anticipated 2014 Inpatient Prospective Payment System (“IPPS”) Final Rule (the “2014 IPPS Final Rule”). The 2014 IPPS Final Rule will be effective on October 1, 2013. There are two main aspects of the 2014 IPPS Final Rule that will significantly […]

On August 2, 2013, the Centers for Medicare & Medicaid Services (“CMS”) issued its highly anticipated 2014 inpatient prospective payment system (“IPPS”) Final Rule (the “Final Rule”). Within this Final Rule, CMS finalized (1) its new requirements for Medicare Part A coverage of inpatient hospital admissions; and (2) its Part B inpatient rebilling policies. Medicare […]

On May 9th, the Centers for Medicare and Medicaid Services (CMS) announced the start of a procurement process for new Medicare Fee for Service Recovery Audit Program contracts. The General Services Administration issued a Request for Quotes (RFQ) seeking four A/B Recovery Auditors, one national Durable Medical Equipment auditor and one Home Health/Hospice Recovery Auditor. […]