Sheppard Mullin

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CMS Plans To Reopen Cap Demands Forever

In recent weeks, hospice providers have been receiving revised cap demands for fiscal years 2012 and earlier.  Although the initial demands in these cases were issued more than three years earlier, CMS now claims that it can reopen and revise cap demands for up to three years from the most recent demand.  Based upon this … Continue Reading

ALJ Now Dismissing Hospice Appeals For Allegedly Insufficient Service On Beneficiary

In the last few years, we have seen a growing and alarming trend of administrative law judges (“ALJ”) dismissing appeals solely based on purported lack of service to the hospice patient (the Medicare beneficiary).  A search of recent decisions shows over 150 such cases at the Medicare Appeals Council starting in 2012 and continuing to … Continue Reading

Attending Physician Documentation Changes Increase Audit Risk

On October 1, 2014, CMS revised its attending physician requirements, setting another potential trap for the unwary.  42 C.F.R. 418.24 [Election of Hospice]. While statute and regulation have long required both the attending physician and hospice medical director to certify initial eligibility, CMS has now tightened regulation around identification and change of attending physician.  The … Continue Reading

ZPIC/RAC/ADR Appeals Deadline Desk Calendar

The attached table identifies each level of appeal available to providers facing either pre- or post-payment claims denials, whether through ADR edits, probe edits, Zone Program Integrity Contractors, or RAC auditors.  The table identifies deadlines to file appeals of initial or revised determinations at each level and also provides tips to help ensure that appeals are … Continue Reading
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