On February 21, 2024, CMS published a transmittal on its website with instructions for Medicare Administrative Contractors (MACs) to implement CMS’s final rule, issued June 9, 2023, concerning the treatment of the Part C days...more
On September 27, 2023, Judge Royce Lamberth of the United States District Court for the District of Columbia dismissed a lawsuit challenging HHS’s calculation of the standardized amount used in calculating Medicare Inpatient...more
On September 1, 2023, the D.C. Circuit affirmed the D.C. District Court’s decision in Pomona Valley Hosp. Med. Ctr. v. Azar, 2020 WL 5816486, at *1 (D.D.C. Sept. 30, 2020) requiring CMS to produce affirmative evidence as to...more
On March 29, 2021, Judge Margaret B. Seymour, in the United States District Court for the District of South Carolina, set aside a decision from CMS’s Provider Reimbursement Review Board (Board) denying reimbursement relating...more
In a significant break from preceding court decisions, the United States District Court for the District of Columbia recently struck down CMS's "must bill" policy, which requires that Medicare providers bill Medicaid and...more
On Thursday, February 28, 2019, two years after hearing arguments in lead group cases, the Provider Reimbursement Review Board affirmed CMS’ approach to counting sequestered funds as part of provider revenue for hospice cap...more
In a decision with implications that could go back 35 years, the United States Court of Appeals for the District of Columbia Circuit rejected a CMS interpretation of its reopening rules as that interpretation affects current...more
On April 23, 2018, CMS released CMS-1727-R (the Ruling), which announced that it will follow the United States District Court’s decision in Banner Heart Hospital v. Burwell, 201 F. Supp. 3d 131 (D.D.C. 2016). The Banner...more
Last week, the United States District Court for the District of Columbia denied CMS’s request to remand to the Provider Reimbursement Review Board (PRRB) the claims of several hospitals who sought expedited judicial review...more
On March 21, 2017, the U.S. District Court for the District of Columbia ruled that a hospital lacked standing to challenge a decision of the Provider Reimbursement Review Board (the “PRRB”), since the hospital failed to...more
In Banner Heart Hospital, et al. v. Burwell, the United States District Court for the District of Columbia (Court) held on August 19, 2016, that the Provider Reimbursement Review Board (PRRB) incorrectly declined to hear an...more
Effective July 1, 2015, the Provider Reimbursement Review Board (PRRB or Board) has promulgated new rules regarding the reinstatement and withdrawal of appeals before the Board. The most significant change is a new rule...more
CMS recently issued Ruling 1498-R2 (Ruling), dated April 22, 2015, amending its 2010 Ruling 1498-R. The new Ruling addresses the calculation of the Medicare fraction of the disproportionate share hospital (DSH) adjustment for...more
On August 6, 2014, the United States District Court for the District of Columbia enjoined CMS, its Medicare Administrative Contractors (MACs), and the Provider Reimbursement Review Board (PRRB) from applying the...more
On Tuesday of last week the D.C. Circuit Court ruled that the Provider Review Reimbursement Board doesn’t know what’s new. It reversed the PRRB’s decision, along with the District Court’s decision that upheld it. In doing...more
Medicare claims processing activities continue during the shutdown. PRRB appeal deadlines, although temporarily suspended, will become due immediately on the day the government reopens. Federal court deadlines remain in...more
The Provider Reimbursement Review Board (PRRB) has issued a decision upholding CMS’s policy of not recognizing pension expenses for purposes of calculating the wage index unless such expenses are liquidated within one year. ...more
On March 1, 2013, the Provider Reimbursement Review Board (PRRB or the Board) issued Alert 9, which notified interested parties that the PRRB has made revisions to its Rules and updated its Model Forms. Medicare providers...more
In recently released decisions, the PRRB and the CMS Administrator addressed a number of issues of interest to many providers. Short summaries of those decisions are provided below. The PRRB and CMS Administrator post their...more