Court Dismisses AHA’s Challenge to CMS Billing Policy

Court Dismisses AHA’s Challenge to CMS Billing Policy

Court Dismisses AHA’s Challenge to CMS Billing Policy


On September 17, 2014, the U.S. District Court for that District of Columbia ignored a suit introduced through the American Hospital Association (AHA), three individual hospitals, and 2 healthcare systems that challenged CMS’s “Part B inpatient” billing policies. Am. Hosp. Ass’n v. Burwell, No. 12-1770-CKK (D.D.C. Sept. 17, 2014). A legal court ignored the situation for insufficient jurisdiction.

AHA filed this suit this year, challenging a CMS policy that seriously restricts hospitals’ capability to bill Medicare Medicare Part B for medically necessary services presented to inpatients following a denial from the inpatient stay because, within the CMS contractor’s view, the help must have been provided within an outpatient setting. AHA challenged CMS’s requirement that hospitals must submit “new” Medicare Part B claims following a Medicare Part A denial, instead of permitting hospitals to amend or supplement the present Medicare Part A claim. AHA also challenged CMS’s policy that any “new” Medicare Part B claims be filed within twelve months following the date and services information, citing the truth that just about all Medicare contractor denials, especially recovery audit contractor (RAC) denials, come at least a year following the date and services information. AHA contended that CMS’s failure to produce a categorical exception towards the one-year timely filing requirement under these conditions was arbitrary and capricious.

A legal court didn’t address these challenges on their own merits. Rather, a legal court held that it didn’t have jurisdiction underneath the Medicare statute. Underneath the Medicare statute, judicial review can be obtained only “after a[] ultimate decision from the [Secretary] made following a hearing,” and CMS has narrowly defined what is really a “final decision,” the most typical example being a denied claim for Medicare reimbursement. A legal court found, however, that CMS’s failure to create the best to the timeliness policy doesn’t embody an appealable “final decision,” but is quite a “non-exercise from the agency’s discretion.” Similarly, a legal court held that the necessity to submit a brand new Medicare Part B claim following a Medicare Part A denial, instead of permit amending the formerly filed claim seemed to be a “non-existent decision . . . [and] not among the groups of ultimate decisions which judicial review is permitted.”

AHA had contended when a legal court was without jurisdiction underneath the Medicare statute, it had federal question jurisdiction under 28 U.S.C. § 1331. Generally, the Medicare statute mandates that all legal challenges towards the agency’s final decisions be channeled with the agency’s five-level administrative appeals process before they may be filed in federal court. However the Top Court has recognized the best for this channeling requirement “when roadblocks practically stop any avenue to federal court, . . . [so that] judicial review [is] unavailable like a practical matter.” Am. Chiropractic Ass’n. v. Leavitt, 431 F.3d 812, 816 (2005) (citing Shalala v. Illinois Council on Lengthy Term Care, 529 U.S. 1, 22-23 (2000)). Ultimately, AHA couldn’t show it met this exception because other hospitals had effectively challenged CMS’s refusal to rebill under Medicare Part B and received favorable decisions in the Departmental Appeals Board awarding reimbursement under Medicare Part B. Even when AHA’s member hospitals were unsuccessful such an appeal, a legal court reasoned, they might then obtain judicial overview of that administrative decision. The entire decision can be obtained here. The appropriate Final Rule regarding CMS insurance policy for Medicare Part B rebilling following a RAC denial for Medicare Part A claims can be obtained here. 78 Given. Reg. 50,496, 50,906 (August. 19, 2013).

Reporter, Elizabeth N. Swayne, Washington, D.C., 1 202 383 8932, [email protected]



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