Filed December 8, 2017
19 Universal Health Services, Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989 (2016) ................................................................................ passim STATUTES AND REGULATIONS 31 U.S.C.§ 3729(a)(1)(G) .................................................................................... 2, 11 31 U.S.C. § 3731(b) ................................................................................................. 20 42 U.S.C. § 1395c et seq. .......................................................................................... 3 42 U.S.C. § 1395j et seq. ........................................................................................... 3 42 U.S.C. § 1395w-21 et seq. .................................................................................... 4 42 U.S.C. § 1395w-23 ............................................................................................... 4 42 U.S.C. § 1395w-23(a)(1)(B) ................................................................................. 4 42 U.S.C. § 1395w-24(a)(6)(A)................................................................................. 4 Pub. L. No. 111-21, 123 Stat. 1617 (2009) ....................................................... 19, 20 42 C.F.R. § 422.254(b)(1) ......................................................................................... 4 74 Fed. Reg. 54,634 (Oct. 22, 2009) ......................................................................... 7 OTHER AUTHORITIES CMS, Notice of Final Payment Error Calculation Methodology (Feb. 24, 201
Filed June 27, 2017
Medicare Part A generally covers inpatient hospital services and other institutional care (e.g., skilled nursing facility services), while Part B, implicated here, covers other medical items and services, including physicians’ services, hospital outpatient services, and diagnostic testing performed by clinical laboratories. See 42 U.S.C. § 1395c; 42 U.S.C. § 1395j; 42 U.S.C. § 1395k(a)(1). “Notwithstanding any other provision of [the Medicare statute], no payment may be made under part A or part B . . . for any expenses incurred or items or services, which . . . are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Filed May 12, 2017
Part B benefits are supplemental health insurance benefits that cover certain physician, diagnostic, and other outpatient services for beneficiaries who voluntarily enroll and pay additional premiums. 42 U.S.C. §§ 1395j to 1395w-4; 42 C.F.R. Parts 407, 410. The Centers for Medicare & Medicaid Services (“CMS”) is the component of the Department of Health and Human Services (“HHS”) responsible for the administration of the Medicare program in conjunction with private entities known as Medicare Administrative Contractors (“MACs”) with which the Case 6:16-cv-00868-CEM-DCI Document 32 Filed 05/12/17 Page 2 of 20 PageID 642 3 Secretary enters into contracts pursuant to 42 U.S.C. §1395kk-1(a).2 See also 42 U.S.C. §1395u(a); Schweiker v. McClure, 456 U.S. 188, 190-91 (1982).
Filed July 8, 2016
Only Part B, which was established in Section 1831 of the Medicare statute, is relevant here. See 42 U.S.C. § 1395j. The Medicare statute and regulations create a program of “defined and limited benefits” that are tethered to “specific practitioner qualification requirements that aim to ensure that program beneficiaries receive high quality health care.”
Filed December 13, 2012
Part B of the Medicare Program (“Part B”) authorizes payment for various medical and other health services and supplies, including outpatient services. See 42 U.S.C. § 1395j, et. seq.
Filed July 17, 2007
Before the recent extension of Medicare to cover a portion of prescription drug costs, Medicare covered only inpatient care through Part A and outpatient care through Part B. Parts A and B are fee-for-service insurance programs operated by the federal government. 42 U.S.C. § 1395c et seq. (Part A); 42 U.S.C. § 1395j et seq. (Part B). In 1997 Congress enacted Medicare Part C to allow Medicare beneficiaries to opt out of traditional fee-for-service coverage under Parts A and B. 42 U.S.C. § 1395w-21 et seq. (Part C).