Becker's Hospital Review

23 CFO / FINANCE UnitedHealthcare loses Medicare overpayment appeal: 5 things to know By Morgan Haefner A federal appeals court ruled against UnitedHealthcare Aug. 13 in a case involving Medicare Advantage overpayments. Five things to know: 1. In a 49-page opinion, the U.S. Court of Appeals for the District of Columbia Circuit reversed a 2018 decision that vacated Medicare's overpayment rule, which requires insurers to refund pay- ment to CMS within 60 days if it learns a diagnosis lacks medical record support. 2. UnitedHealthcare had argued the overpayment rule was subject to "actu- arial equivalence." However, the court ruled actuarial equivalence doesn't apply to the overpayment rule, and there's no legal basis for UnitedHealthcare's claim. 3. "Even if actuarial equivalence applied as UnitedHealth suggests, it would be UnitedHealth's burden to show the systematically skewed inaccuracies on which its theory depends, which it has not done," the court ruled. "Also fatal to UnitedHealth's claim is that it never challenged the values CMS assigned to the risk factors it identified or the lev- el of the capitation payments resulting from CMS's risk-adjustment model." 4. The court rejected UnitedHealth's claims that the overpayment rule vio- lates the statute's "same methodology" requirement, as well as its argument that the rule is arbitrary and capricious for the same reasons. 5. CMS has been targeting Medicare overpayments, with the agency saying health insurers have overcharged the program by nearly $30 million in recent years. CMS argues Medicare Advantage insurers are overcharging the govern- ment through elevated risk scores that exaggerate how sick patients are. n CHS to end inpatient, surgical care at Pennsylvania hospital By Ayla Ellison T yler Memorial Hospital in Tunkhannock, Pa., owned by Franklin, Tenn.- based Community Health Systems, will end surgical and acute inpatient care Sept. 17, but the hospital will continue to offer emergency and out- patient services. The 48-bed hospital's leaders will work with medical staff, patients and first responders to ensure a smooth transition of care when surgical services and acute inpatient care end, according to an Aug. 30 news release. Tyler Memorial Hospital, which operates as part of the Commonwealth Health network, was slated to close its emergency department Oct. 23, according to a notice filed with the state in July. Hospital leaders, the Pennsylvania Depart- ment of Health and elected officials worked together to develop a plan for the hospital to keep emergency department services. "Emergency medicine is a vital component of the health care continuum and we're pleased to sustain access locally," Mark Mitchell, board chair at Tyler Memorial Hospital, said in an Aug. 30 news release. On Oct. 1, Tyler Memorial Hospital will begin operating as a campus of Region- al Hospital of Scranton (Pa.), which is also part of Commonwealth Health. n Mount Sinai Health System receives $60M gift for new cancer center in Manhattan By Alia Paavola M ount Sinai Health System received a $60 million gi to support the creation of a cancer center and construction of a new cancer hospital in Manhattan, the New York City-based system said Aug. 23. e gi from James and Merryl Tisch is the largest gi received by the health system for a cancer initiative. Previously, the Tisch family donated $40 million in 2008 to establish the Tisch Cancer Institute at Icahn Mount Sinai. e $60 million gi will support construction of a four-story hospital and establish the Mount Sinai Tisch Cancer Center. e Mount Sinai Tisch Cancer Center will include the Tisch Cancer Hospital, the Tisch Cancer Institute at Icahn Mount Sinai, several cancer centers and several ambulatory can- cer care sites. e new Tisch Cancer Hospital is expected to be completed by 2025. It will house about 20 single-bed rooms on each of the four floors and a series of clinical spaces to ease tran- sitions between the various stages of treatment. e cancer center aims to broaden access to therapies, diagnostics and clinical trials. "We are so grateful to Jim and Merryl for their continued and outstanding support of Mount Sinai, and we are deeply honored that the new hospital will bear the Tisch name," said Kenneth Davis, MD, president and CEO of Mount Sinai Health System. "eir ongoing generosity helps us elevate the level of cancer care all patients receive at Mount Sinai." n

• Cover