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Tag Archives: Medicare

Administrative – Medicare – Convicted Doctor – Hydrocodone Samples – Statutory Ban

Morgan v. Sebelius A physician who obtained hydrocodone samples for his personal use by misleading sales representatives into believing the samples were for patients, and who pleaded guilty to knowingly obtaining a controlled substance by fraud, cannot avoid the ban on participating in the Medicare and Medicaid programs by arguing that the statutory ban under 42 U.S.C. § 1320a-7(a)(3) only applies to “financial misconduct”; the 4th Circuit dismisses the physician’s challenge to application of the ban.

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Administrative – Medicare – Reimbursement – 1995 & 1997 Guidelines – Estoppel – Dated Record – Medical Complexity

Ojebuoboh v. Sebelius The plaintiff-doctor did not raise the issue of which set of Medicare Guidelines (the 1995 version or the 1997 version) applied until his motion for reconsideration before the Medicare Appeals Council (MAC). Accordingly, the MAC’s adoption of the independent reviewer’s decision to use the 1997 guidelines was not arbitrary, capricious, or an abuse of discretion.

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Administrative – Medicare – Denial of Coverage – Arthritis Treatment

Almy v. Sebelius The 4th Circuit upholds the Secretary of Health and Human Services’ denial of Medicare Part B coverage for the BIO-1000, a device to treat osteoarthritis of the knee, rejecting the claims of the manufacturer’s bankruptcy trustee that the Secretary improperly used the adjudicative process to develop a policy denying coverage and her decisions were arbitrary and capricious.

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