On April 22, 2014, the US Department of Health and Human Services Office of Civil Rights (OCR) announced settlements of close to $2 million with two health care entities for violations of the Privacy and Security Rules promulgated under the Heath Insurance Portability and Accountability Act (collectively HIPAA) related to the theft of unencrypted laptops.
In an important victory for health care providers, a federal district court in Illinois recently held that health plans may not simply unilaterally recover overpaid funds from health care providers, but rather must provide the appeal and other procedural protections required under the federal Employee Retirement Income Security Act (ERISA) and its implementing regulations. While it has long been the rule that ERISA’s appeal and other procedural rights must be allowed when ERISA plans issue “adverse benefit determinations” on claims submitted for reimbursement, it has not always been clear that these same procedures are required with respect to recoupment decisions. In Pennsylvania Chiropractic Association v. Blue Cross Blue Shield Association, No. 09 C 5619, 2014 WL 1276585 (N.D. Ill. Mar.
A December 31 memo from Nancy Griswold, Chief Administrative Law Judge (ALJ) of the Office of Medicare Hearings and Appeals (OMHA), delivered bad news to health care providers and suppliers awaiting resolution of long-standing health care appeals. The news confirmed what many who have waited years to have their cases heard had suspected — that OMHA is buckling under the backlog of 357,000 appeals awaiting adjudication by 64 ALJs across its four regional offices.
Nearly 350 providers, suppliers, consultants, and beneficiary representatives convened at a February 12 OMHA forum, while over 600 listened in on audio and web feeds to hear Judge Griswold and others talk about the problems confounding the current system and voice frustration over the lack of confidence in the Centers for Medicare and Medicaid Services (CMS) and contractor led-lower level appeals.
Earlier this month, Arent Fox Health Care partner Lowell C. Brown published an article in California Healthcare News that provides insight into a key peer review case involving legal principles and individual behaviors that provide critical lessons for hospitals.
In the article, Mr. Brown reports that “Michalski was about sexual harassment, an errant hearing committee decision, and a governing body’s ultimate authority to decide what physician behavior is acceptable in the hospital. In its decision the California Court of Appeal confirmed that a hospital’s governing body may, where permitted by the hospital’s medical staff bylaws, broadly exercise its independent judgment and overturn a Judicial Review Committee (JRC) decision following a peer review hearing.”
The latest report published by the American Hospital Association (AHA) detailing the results of its RAC Trac survey1 reveals that RAC activity in hospitals has significantly increased in 2013. Not surprisingly, the financial impact of this increased RAC activity has grown substantially as well, both in terms of claims denials and the costs associated with responding to the RACs. Nevertheless, hospitals that have challenged denials of claims by RACs, either through the appeal process or through utilization of the discussion period, have had significant success in overturning denials.
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