Administrative Law, Insurance

DOES AUTHORITY EXIST FOR CRIMINAL PROSECUTION FOR VIOLATIONS OF BAIL LICENSING LAWS WITHOUT CERTIFICATION OF CRIMES BY THE...

by Bonnie Merrick on 5/6/2013

California attorney Joseph Cavallo was convicted of violating Title 10, CCR section 2071, "recommendation of attorney by bail licensee". The authority to prosecute violations of the bail licensing regulations lies with the...more

Court Grants Unexpected Victory to Providers on Medicare DSH Adjustment

by Thomas W. Coons, Mark A. Stanley | Ober|Kaler on 4/18/2013

The United States District Court for the Eastern District of Pennsylvania’s opinion in Nazareth Hosp. v. Sebelius, slip op. no. 10-3513 furnished a surprising victory to two providers that challenged the calculation of the...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

by Womble Carlyle Sandridge & Rice, PLLC on 4/17/2013

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

Judge Invalidates California Regulation on Estimating Replacement Costs for Homeowners Insurance

by Larry Golub, Samuel Sorich | Barger & Wolen on 4/4/2013

On March 25, 2013, Los Angeles Superior Court Judge Gregory Alarcon issued a decision which found the California Department of Insurance’s regulation on estimating replacement costs for homeowners insurance to be invalid. The...more

CMS Revises Part B Billing Policy for Unnecessary Inpatient Admissions

by Thomas W. Coons, Carel Hedlund | Ober|Kaler on 3/29/2013

For many years, CMS policy has been that, if an inpatient admission was denied for medical necessity reasons, the hospital could bill under Part B for only a limited set of services that, significantly, did not include...more

Subrogation Claims are “Equitable Relief” Governed by ERISA

by D. Michael Reilly | Lane Powell PC - ERISA Law on 3/26/2013

That subrogation claim you have might be governed by ERISA, at least in some circuits… Here’s the case of Thurber v. Aetna Life Insurance Company, __F.3d__ (2nd Cir. March 13, 2013) (Insurer’s counterclaim for return...more

Resubmission of Hospital Claims

by Thomas Hess, Tyler N. Williams | Dinsmore & Shohl LLP on 3/13/2013

On February 13, CGS Administrators, the Parts A and B Medicare Administrative Contractor for Kentucky and Ohio, relayed instructions to Medicare hospitals paid under the Inpatient Prospective Payment System from the Centers...more

Federal Healthcare Fraud Enforcement Efforts Yield a 790% Return

by B. Scott McBride, Gregory Saikin | BakerHostetler on 2/28/2013

Last week, the U.S. Department of Health and Human Services (HHS) and the DOJ jointly released a report concluding that, for every dollar spent on healthcare fraud investigations in the last three years, the government...more

8th Circuit – Expressing Intent to Appeal in the Future Does Not Constitute an “Appeal.”

by Lane Powell PC - ERISA Law on 2/20/2013

How does an ERISA claimant start an administrative appeal? Can a mere request for medical records, and a reference to an “appeal in the future tense,” trigger the appeal? No....more

Payment Matters: No Judicial Review of Contractor’s Finding of a High Payment Error Rate, a Condition for Extrapolation

by Mark A. Stanley | Ober|Kaler on 2/11/2013

Before a Medicare contractor can use extrapolation to determine an overpayment amount, the Medicare statute requires that it must make a finding that there is a sustained or high level of payment error or that documented...more

Payment Matters: Supreme Court: Providers' Appeal Period Not Extended by Doctrine of Equitable Tolling

by Thomas W. Coons | Ober|Kaler on 2/7/2013

Under the Medicare statute and implementing regulation, providers have 180 days from the issuance of a Notice of Program Reimbursement (NPR) in which to file an appeal to the Provider Reimbursement Review Board (PRRB). This...more

U.S. Supreme Court Holds Equitable Tolling Doctrine Does Not Apply To Administrative Appeal Deadline

by Anastasia (Ana) K. Anderson, Renee M. Howard, David B. Robbins | Perkins Coie on 1/28/2013

On January 22, 2013, the U.S. Supreme Court issued a unanimous decision in Sebelius v. Auburn Regional Medical Center, 568 U.S. _____ (2013), holding that hospitals cannot appeal Medicare inpatient reimbursement...more

BMA Announces Principles Underpinning Use of New Powers

by Mark Chudleigh, Nick Miles | Sedgwick LLP on 1/25/2013

The Bermuda Monetary Authority (the BMA) has published a new statement of practice (SoP). It sets out factors to which it will have regard and procedures to be followed in deciding whether and in what manner to exercise...more

OIG Advisory Opinion Sheds Light On Pay-For-Performance Relationships Between Hospitals And Physicians

by Darby C. Allen, Donna S. Clark | BakerHostetler on 1/20/2013

On January 7, 2013, the HHS OIG released Advisory Opinion 12-22 concerning a rural hospital's (Hospital) proposal to pay a cardiology group (Group) a performance bonus for achieving certain patient service, quality and cost...more

Payment Matters: CMS Acknowledges Transitional Care Management as Separate Service from E/M

by Julie Kass | Ober|Kaler on 1/18/2013

Recognizing that care coordination is a key component to achieving better care and health for individuals and reducing expenditure growth, CMS has implemented several new programs to provide payment for such services,...more

OIG: Cardiac Catheterization Arrangement Between Hospital and Physicians Not Subject to Sanctions

by King & Spalding on 1/18/2013

On January 7, 2013, HHS OIG published a favorable advisory opinion on a management arrangement between a hospital and a cardiology group related to the provision of certain cardiac catheterization services at the hospital. ...more

What To Do If The Feds Come Knocking At Your Door!

by Jacqueline Arango, Ari H. Gerstin, Bruce Platt, Richard Sharpstein | Akerman Senterfitt on 1/18/2013

Your employee handbook likely addresses, in great detail, the do's and don'ts of using the internet while at the office, guidance on HIPAA, and even the company's policy on sexual harassment, but does it provide any...more

Health Reform + Related Health Policy News Update - January 16, 2013

by Colleen M. Faddick, Bruce A. Johnson, Matthew Murer, Alan K. Parver | Polsinelli on 1/18/2013

In This Issue: - Fiscal Cliff Deal Lengthens Medicare Overpayment Recovery Period - Cutting Medicaid Provider Tax May Shift Costs to States, CRS Finds - MedPAC Finalizes Payment Recommendations, GAO Solicits...more

Governmental Actions That May Assist Insurance Recovery for Superstorm Sandy Claims [UPDATED]

by Lynda A. Bennett, Andrew S. Zimmerman | Lowenstein Sandler LLP on 1/18/2013

Following the widespread destruction caused by “Superstorm Sandy,” the governors of New York and New Jersey declared states of emergency and issued numerous emergency executive orders and directives. Some of these orders have...more

Labor & Employment Law Update - January 2013 : New Year Employer Checklist

by Jeffrey Bell, Andrew Cripe, Jay Dade, Bradley Kafka, William P. Sweeney | Polsinelli on 1/17/2013

In This Issue: - New Health Care Mandates - I-9's for Immigration in 2013 - A Policies and Procedures Review - Classifying Employees as Exempt or Non-Exempt? - Awareness of National Labor Relations Board...more

Take 5: Views You Can Use - January 2013

by Greta Ravitsky | Epstein Becker & Green, P.C. on 1/17/2013

In this issue: - Assess the Workforce - Choose Whether to "Pay" or to "Play" - Evaluate Existing Wellness Programs and/or Implement New Wellness Programs to Enhance Employees' Health Profiles and to Avoid or Minimize...more

Health Care Reform: Recent Guidance on "Play or Pay" Rules for Applicable Large Employers in 2014

by Beth Alcalde, Elizabeth F. Hodge, Carolyn Kershner, Leanne Reagan | Akerman Senterfitt on 1/17/2013

Many important aspects of the Patient Protection and Affordable Care Act ("ACA") will go into effect in 2014, including the implementation of health insurance exchanges, and the requirement for certain employers to offer...more

Michigan Court of Appeals Approves Health Benefits for Unrelated Co-Residents of State Employees

by Scott Eldridge | Miller Canfield on 1/17/2013

On January 8, 2013, the Michigan Court of Appeals, in a two-to-one decision, held that the Michigan Civil Service Commission could extend eligibility in the State Health Plan to “other eligible adult individuals” (OEAI) who...more

Health Care Reform Update: Many Self-Insured Plans Subject to New Annual Fees This Year

by Mark Jones, Justin Krawitz | Pillsbury Winthrop Shaw Pittman LLP on 1/17/2013

New regulations have been issued under the Patient Protection and Affordable Care Act (“PPACA”) implementing annual fees and reporting requirements on self-insured health plans and indirectly on fully insured plans. The...more

Deferral of the Swaps Push-Out Requirement, But Only for Insured Federal Depository Institutions

by Ian Cuillerier, Ernest (Ernie) T. Patrikis, Duane D. Wall | White & Case LLP on 1/17/2013

An insured federal depository institution may request a transition period to comply with the “push-out” requirements of section 716 of the Dodd-Frank Wall Street Reform and Consumer Protection Act (the “Dodd-Frank Act”)...more

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Administrative Law › Insurance