The U.S. Supreme Court recently issued a unanimous decision in Rutledge v. Pharmaceutical Care Management Ass’n, which supports the validity of state statutes that regulate reimbursement rates pharmacy benefit managers (PBMs)...more
12/23/2020
/ Drug Pricing ,
Employee Retirement Income Security Act (ERISA) ,
Health Insurance ,
Pharmaceutical Industry ,
Pharmacies ,
Pharmacy Benefit Manager (PBM) ,
Preemption ,
Prescription Drug Coverage ,
Prescription Drugs ,
Rutledge v Pharmaceutical Care Management Association ,
SCOTUS
In this week’s episode, Gary Qualls discusses a recent case decided in the Western District of Louisiana, which highlights how the application of the arbitrary and capricious standard as applied to payor coverage...more
8/6/2020
/ Abuse of Discretion ,
Appeals ,
Arbitrary and Capricious ,
Blue Cross ,
Denial of Benefits ,
Denial of Insurance Coverage ,
Health Care Providers ,
Health Insurance ,
Healthcare Facilities ,
Inpatient Billing ,
Insurance Litigation ,
Medical Necessity ,
Mental Health ,
Motion for Summary Judgment ,
Physicians ,
Substantial Evidence ,
Suicide
In this episode, Gary Qualls discusses a recent development in payer litigation which implicates a number of recurring issues often raised in Employee Retirement Income Security Act (ERISA) cases. Specifically, a federal...more
2/7/2019
/ Administrative Remedies ,
Anti-Assignment Clauses ,
Assignment of Benefits (AOB) ,
Breach of Duty ,
Employee Retirement Income Security Act (ERISA) ,
Fiduciary Duty ,
Health Care Providers ,
Health Insurance ,
Hospitals ,
Motion to Dismiss ,
Patients ,
Payor Contracts ,
Plan Administrators ,
Preemption
In this episode, Gary Qualls discusses a recent development in payer litigation, regarding a provider’s recovery of Medicare Advantage payments pursuant to a Medicare Advantage contract. Specifically, a recent federal case...more
7/26/2018
/ Administrative Appeals ,
Administrative Remedies ,
Breach of Contract ,
Centers for Medicare & Medicaid Services (CMS) ,
Health Care Providers ,
Health Insurance ,
Hospitals ,
Insurer Liability ,
Jurisdiction ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Patients ,
Payor Contracts ,
Preemption ,
State Law Claims ,
Underpayment
The existence and scope of assignments of benefits from patients to health care providers continues to be critically important to a provider’s ability to challenge an insurer’s reimbursement decision under the Employee...more
There is a growing likelihood that the current administration will terminate funding for the Affordable Care Act’s (ACA) cost sharing reduction (CSR) subsidies some time within the next two months. The administration has the...more