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Ch-Ch-Ch-Ch-Changes: Reporting Requirements for Updating Your CMS Provider Enrollment

With the possibility of significant penalties for improperly reported transactions, it is important to understand how certain changes necessitate specific reporting. Is your organization considering a stock transfer, a merger, a change in control, building a new practice location or updating its board of directors? If these kinds of changes are afoot, it is critical … Continue Reading

Doc, Can You Hear Me Now? Telehealth Finally Comes of Age in Texas

After many years of heated and contentious debate, and opposition by the Texas Medical Association and the executive director of the Texas Medical Board, Texas has significantly revised its telemedicine statute to permit the routine provision of telemedicine services addressing litigation brought against the Texas Medical Board and reflecting the changing consensus regarding telemedicine services. … Continue Reading

Exaggerated Diagnosis Codes and Inadequate Provider Networks: Allegations of Medicare Advantage Fraud Settled for $32.5 Million

The latest settlement involving Medicare Advantage (MA) organizations highlights not only the government’s continuing enforcement focus on Medicare Part C but also the vulnerabilities inherent in that program. In United States ex rel. Sewell v. Freedom Health, Inc. et al., two Florida-based MA organizations – Freedom Health and Optimum HealthCare – agreed to pay $32.5 … Continue Reading

Capitol Hill Healthcare Update

Senate Presses Ahead on Healthcare Talks as Deadline Looms With only 10 legislative days before Senate Republicans’ self-imposed deadline, GOP lawmakers face growing obstacles in their quest to vote on replacing the Affordable Care Act (ACA) before the beginning of their scheduled Fourth of July recess. Still, Majority Leader Mitch McConnell (R-Ky.) wants a vote … Continue Reading

Branded Biologic Products Lose 180 Days of Patent Exclusivity in Unanimous Decision From Supreme Court

On June 13, 2017, the U.S. Supreme Court issued its opinion in Sandoz v. Amgen. In doing so, it answered two questions raised under the Biologics Price Competition and Innovation Act of 2009 (BPCI). First, is an injunction available under federal law if the biosimilar applicant fails to provide its application and manufacturing information to … Continue Reading

Capitol Hill Healthcare Update

Senate GOP Still Talking on Health Bill as Clock Ticks Senate Republicans continue intra-party discussions on changes to House-passed legislation replacing the Affordable Care Act (ACA), but the lack of consensus is threatening GOP leaders’ pledge to have a bill ready for a vote this month. Led by Senate Majority Leader Mitch McConnell, key Republican … Continue Reading

Specificity Sometimes Key; Sometimes Not

Time spent drafting and negotiating an agreement often pays dividends in assuring that each party gets the benefits they desire through the agreement and incurs obligations no greater than they intended. Two recent cases, discussed below, demonstrate how small drafting oversights resulted in significant litigation costs to the parties and in one case, the party’s … Continue Reading

The DOJ Enters Another FCA Lawsuit Against UnitedHealth

The U.S. Department of Justice (DOJ) recently filed its complaint in intervention in another whistleblower lawsuit brought under the False Claims Act against the nation’s largest owner and operator of Medicare Advantage (MA) organizations, UnitedHealth Group, Inc. (United). The DOJ’s 39-page complaint alleges that United had fraudulently obtained inflated risk adjustment payments by over reporting diagnosis … Continue Reading

No More Tears: A Few Recommended Steps in Response to WannaCry Ransomware

The attack resulted in some hospitals canceling operations and appointments because critical patient data could not be accessed. On May 12, 2017, thousands of companies across the globe saw the first signs of a prolific malware outbreak. The malware, a ransomware variant labeled WannaCry, is capable of encrypting files on a device and moving laterally … Continue Reading

Capitol Hill Healthcare Update

CBO Score of House Health Bill Set for This Week Congress’s official budget scorekeepers this week will release analysis of the House-approved bill repealing most of the Affordable Care Act (ACA), and that data will inform Senate Republicans on a path for passing their version of the legislation. The Congressional Budget Office (CBO) and the … Continue Reading

Capitol Hill Healthcare Update

Senate Panel OKs FDA User Fees Legislation reauthorizing FDA user fees for prescription and generic drugs, biosimilars, and medical devices won wide bipartisan approval last week in a Senate committee, teeing up approval by the full Senate, likely after the Memorial Day recess. The Senate HELP Committee approved the five-year renewal on a 21-2 vote. … Continue Reading

EMTALA Laboring Along 30 Years Later

The Emergency Medical Treatment and Active Labor Act (EMTALA), despite being enacted more than 30 years ago, has produced a case examining the applicability of malpractice damages limitations that bears watching. In Scott v. Ruston Louisiana Hospital Company, the court examined whether state medical malpractice caps are applicable to an EMTALA case. A young patient … Continue Reading

IPPS Proposed Rule Increases Hospital Payment; Solicits Ideas for Achieving Transparency, Relieving Administrative Burden

The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed rule updating fiscal year (FY) 2018 payment policies and rates under the Medicare inpatient prospective payment system (IPPS). As highlighted below, the proposed rule aims to reduce regulatory burdens for providers and to promote transparency and flexibility in the delivery of care. Comments … Continue Reading

Capitol Hill Healthcare Update

House approval last week of legislation repealing and replacing most of the Affordable Care Act (ACA) sets up a showdown in the Senate, where GOP leaders will confront a familiar web of political, policy and procedural obstacles that took House Republicans five months to navigate. Majority Leader Mitch McConnell and key committee chairmen must reconcile … Continue Reading

We Cured the Breach of Contract! Oh No, You Didn’t

A recent decision from a North Carolina federal court raises interesting lessons for providers surrounding contractual cure and damages provisions. Cone Health entered into a contract with Conifer Physician Services for the provision of revenue management, health information management and billing services. Cone Health has spent a great deal of effort since – litigating whether … Continue Reading

Darwinian Insurance

This case demonstrates the need for providers to know and follow the notification provisions set forth in their insurance policies in order to avoid an inadvertent loss of coverage. Once again, the terms of a hospital’s insurance policy coverage have evolved to a hospital’s detriment. Darwin National Assurance provided first-layer excess liability coverage to a … Continue Reading

Market Stabilization: To Be or Not to Be?

The Centers for Medicare and Medicaid Services (CMS) published a Final Rule intended to stabilize the individual and small group insurance markets on April 18, 2017. Reflecting the urgent need to address the uncertainty afflicting the markets, CMS advanced the rule from proposed to final form in just two short months despite receiving more than … Continue Reading

Bundled Payments Out in the Cold? Another Delay for Mandatory Bundled Payment Models

This most recent delay raises questions concerning how the Trump administration intends to implement value-based payment in the Medicare program. The Centers for Medicare and Medicaid Services (CMS) has delayed again the implementation date of its final rule mandating hospital participation in two new cardiac episode-based payment models (EPMs) and an expansion of the Comprehensive … Continue Reading
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