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Tag Archives: Medicare

Administrative – Medicare – Convicted Doctor – Hydrocodone Samples – Statutory Ban (access required)

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 (access required)

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 (access required)

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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Medicare rules on settlements unite litigators in frustration (access required)

BOSTON, MA — A looming deadline that will require reporting of personal injury settlements to Medicare has united trial lawyers who are normally adversaries in personal injury cases. Under rules designed to protect Medicare’s lien on medical bills recovered by a personal injury plaintiff, liability insurers must begin collecting data on cases that settle on or after Oct. 1 for reporting to the Centers for Medicare and Medicaid Services that is starting Jan. 1, 2012. The deadline has been moved several times in the past three years, purportedly to give CMS more time to create guidelines and to help personal injury cases settle faster.

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