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

On May 13, 2013, the American Orthotic and Prosthetic Association (“AOPA”) filed suit in the federal district court for the District of Columbia against the Centers for Medicare and Medicaid (“CMS”), alleging that payment denials by CMS and its Recovery Audit Contractors (“RAC”) are invalid. The lawsuit states that CMS rules call for denial of […]

Jessica Gustafson, Esq. and Abby Pendleton, Esq., co-chairs of the firm’s Medicare and RAC department authored an ABA Health eSource article titled “CMS Acquiesces to Hospital Pressure, Allows Part B Billing of Hospital Services Following Part A Denial of Inpatient Hospital Claims for Medical Necessity: Is It Enough?” To view this article click here. Continue […]

On March 13, 2013, the Centers for Medicare and Medicaid Services (“CMS”) concurrently issued Ruling CMS-1455-NR (the “Ruling”) and a proposed rule for revising Medicare Part B billing policies in the event of Part A payment denials (the “Proposed Rule”). BACKGROUND Since the conclusion of the Recovery Audit Contractor (“RAC”) demonstration program and prior to […]

On February 19, 2013, the Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) published OIG Report A-05-11-00071 (the “Report”), detailing the results of an audit to determine the adequacy of CMS’ collection of Medicaid overpayments identified in certain OIG audit reports. Under federal regulations (specifically 42 C.F.R. § 433.304), the Secretary […]

CMS has posted on its website the latest RAC statistics. The statistics for the 4th quarter of FY 2012 show CMS collected $648 million in alleged overpayments and returned $46.5 million in underpayments. CMS’ report on the total amounts collected and returned from October 1, 2009 through September 30, 2012, indicates that $3.16 billion in […]

Washington, DC – The Department of Health & Human Services (HHS) Office of Inspector General (OIG) today announced expected recoveries of about $6.9 billion from audits and investigations in its semi-annual report to Congress. The report focuses on OIG accomplishments for the second half of FY 2012 (April 1, 2012 – September 30, 2012) and […]

The U.S. Department of Health and Human Services recently announced that Medicare Part B premiums (i.e., for physician services, outpatient hospital and durable medical equipment) will rise in 2013 by 5%–to $104.90 a month. The deductible for Part B services will increase from $140 in 2012 to $147 in 2013. Part A premiums (i.e., for […]

Abby Pendleton, Esq. and Jessica Gustafson, Esq. of the HLP were quoted in the November 12, 2012 issue of Physician’s Money Digest in an article titled “Putting Practices on the RAC”. Pendleton and Gustafson were interviewed based on their experience in defending health care provider audits around the country and their significant involvement in the […]

On November 1, 2012, the Centers for Medicare and Medicaid Services (“CMS”) released a final Durable Medical Equipment (“DME”) face-to-face policy. As a pre-condition to payment, the rule requires that a beneficiary receive a face-to-face encounter with a Physician, Physician Assistant (“PA”), Nurse Practitioner (“NP”), or Clinical Nurse Specialist (“CNP”) within six months prior to […]

In accordance with New York State’s recently enacted accountable care organization (“ACO”) law (Article 29-E of the New York Public Health Law), the New York State Department of Health (“DOH”) will begin to process applications for Medicare-only ACOs to obtain certification under the new statute. The so-called “fast-track certification” under the statute will grant protection […]