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April 17

Aetna Discontinues Unpopular Observation Notification Policy- But There’s a Catch

By: Emily Blizzard, J.D., Legal Department, Washington & West, LLC In the March 2018 Edition of the Aetna OfficeLink Update, Aetna announced a major change to their observation notification policy. Effective July 1, 2018, Aetna will “no longer require notification for observation greater than 24 hours.” This change will come as a relief to many […] Read More

March 30

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 […] Read More

February 16

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 […] Read More

February 12

An Aetna Medical Director Admitted He “Never Once” Reviewed Medical Records- What Now?

Emily Gillingham, Associate Attorney at Washington & West, LLC Almost every day, one of our hospital clients refers a case to our firm that has us questioning how an insurer could have reached the decision they did. We got a unique look into the inner workings of Aetna’s utilization management department this week with the […] Read More

November 6

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 […] Read More

October 5

American Hospital Association Calls on CMS to Address ‘flaws and inaccuracies’ in OIG Audits

In a letter dated October 2nd, the American Hospital Association has called on CMS to take a more active role regarding hospital compliance reviews conducted by the Office of Inspector General (OIG).  Citing fundamental flaws and inaccuracies, both in the OIG’s understanding and application of Medicare payment rules and in the procedures used to conduct […] Read More

August 28

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 […] Read More

August 15

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 […] Read More

July 25

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 […] Read More

March 10

HHS indicates it cannot eliminate Medicare appeals backlog by the end of 2020

In a status report filed with the U.S. District Court for the District of Columbia HHS indicated that “although the initiatives undertaken by HHS have significantly slowed the growth of the backlog, the significant annual reductions that this court has directed are not possible given current funding and legislative authorities.” The court directive, issued on […] Read More

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