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Author Archives: mshepard

Separating Beneficiary Complaint Review Functions from Quality Improvement Functions On May 9, 2014, the Centers for Medicare & Medicaid Services (CMS) announced the first phase of its restructuring of the QIO functions.  In the first phase, CMS has contracted with Livanta LLC (for geographic areas 1 and 5), located in Annapolis Junction, Maryland, and KePRO … Read more

The Centers for Medicare & Medicaid Services (CMS) is charged with the implementation and oversight of the DMEPOS program.[1]  Since the rollout of the DMEPOS competitive bidding program (CBP) in July, 2008, there has been confusion over what constitutes delivery and set-up of specific DMEPOS items.[2]  In some instances, beneficiaries have experienced delays in obtaining … Read more

To: Medicare Beneficiary Advocates From: Mario D. Ramsey, CMA Health Policy Fellow Subject: GAO and OIG Reports Note No Problems In Beneficiary Access to DMEPOS.  Beneficiary Advocates Disagree. Date: July 8, 2014 Advocates' Concerns about the DMEPOS Reports Advocates are concerned that some suppliers are not delivering and setting-up necessary items of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).[1] … Read more

No. 5:14-cv-128 (D.Vt.), filed June 23, 2014 Issue: Whether the denial of coverage for named plaintiff Glenda Jimmo by the Medicare Appeals Council on re-review of her claim under the revised manual provisions pursuant to the Jimmo settlement agreement was correct. Relief Sought: Reversal of the Secretary’s decision denying coverage and granting the claim for … Read more

 No. 3:08-CV-1148 (AHN) (D. Conn.), filed July 31, 2008 Issue: Whether the use of a "stability" test to terminate home health coverage on the ground that the patient no longer needs skilled nursing care violates the Medicare statute and regulations. Relief Sought: Declaratory judgment, and temporary and permanent injunctive relief on behalf of an individual … Read more

 No. 11-cv-17 (D.Vt.), filed January 18, 2011   Issue: Whether the "Improvement Standard", which operates as a rule of thumb to terminate or deny Medicare coverage to beneficiaries who are not improving, violates substantive and procedural requirements of the Medicare statute, the Administrative Procedure Act, and the Freedom of Information Act, and the Due Process Clause … Read more

No. 14-801 (D.Conn.), filed June 4, 2014 Issue: Whether the Secretary of Health & Human Services’ denial rate of about 98% at the lowest two levels of appeal in Medicare’s system of administrative review (redetermination and reconsideration) violates the Medicare statute and the Due Process Clause. Relief sought: Declaratory and injunctive relief for a Connecticut … Read more

 No. 11-1703 (D.Conn.), filed November 3, 2011 Issue: Whether the Secretary's policy of allowing hospitalized Medicare beneficiaries to be placed in "observation status," rather than formally admitting them, deprives them of their Part A coverage in violation of the Medicare statute, the Administrative Procedure Act, the Freedom of Information Act, and the Due Process Clause.  … Read more

The Supreme Court decision in Burwell, Secretary of Health and Human Services, et al. v. Hobby Lobby Stores, Inc., et al. (5-4 decision), 573 U.S. ___ (2014) is ominous. Not only is the decision, and its interpretation of the Religious Freedom Restoration Act (RFFA) a blow to a woman's access to preventive and contraceptive care, its … Read more

Federal law sets out few specific requirements for nurse staffing.  These requirements have not been revised since they were established by the 1987 Nursing Home Reform Law[1] and became effective on October 1, 1990.  Nursing Home Reform Law and Regulations Numbers of staff: The Reform Law requires that facilities employ a registered nurse (RN) for … Read more