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February 07, 2020

Judge Rejects Motion for Reconsideration in Litigation over 2014 CMS Final Rule

A district court judge has denied a motion from CMS to reconsider her original decision in a case related to a Medicare regulation. The CMS 2014 rule requires a Medicare Advantage plan to report and return, as an overpayment, any diagnosis code not supported by an underlying medical record that the plan either identifies or should have identified through reasonable diligence. The trial court’s decision invalidated the rule on several grounds, including that it violates the statutory mandate of “actuarial equivalence.” On November 5, 2018, the government filed a motion asking the judge to reconsider her holding on actuarial equivalence. The request was based on the government’s newly proposed regulations that reverse a prior decision to use a Fee-for-Service Adjuster in RADV audits, including a study that CMS published in support of the proposed regulations.