Civil Procedure, Health Law, Insurance

Groundhog Day for Tuomey: Jury Finds Hospital Violated Stark Law and False Claims Act

by Darby C. Allen, Donna S. Clark | BakerHostetler on 5/22/2013

On May 8, 2013, a jury in the Columbia Division of the U.S. District Court for the District of South Carolina returned a verdict finding that Tuomey Healthcare Systems, Inc. (Tuomey) violated the Stark Law and the federal...more

Retired County Employees Can Amend Their Complaint In An Attempt To Prove Existence Of A Contract for Health Benefits

by Laura Izon Powell, Bruce A. Scheidt, Kristianne Seargeant, David W. Tyra | Kronick, Moskovitz, Tiedemann & Girard on 5/22/2013

In 2008, the Sonoma County Board of Supervisors (“County”) acted to cap the county’s contributions for health care benefits for retired employees at $500 per month. The Sonoma County Association of Retired Employees...more

OIG Releases Updated Provider Self-Disclosure Protocol

by John T. Bentivoglio, Jennifer L. Bragg, Maya Florence, Michael K. Loucks, Gregory M. Luce | Skadden, Arps, Slate, Meagher & Flom LLP on 5/21/2013

On April 17, 2013, the Office of the Inspector General (OIG) of the United States Department of Health and Human Services released an updated Provider Self-Disclosure Protocol (SDP). As self-described, OIG updated the SDP to...more

Insurance Recovery Law -- May 16, 2013

by Manatt, Phelps & Phillips, LLP on 5/17/2013

In This Issue: Prepare For A Storm of Lawsuits; To Ensure Coverage, Read Policy Carefully; and Ticketmaster Wins Reversal, Possible Coverage For Class Action Over Ticket Fees ...more

SuperVision Today - 2nd Quarter 2013

by Erin Jones Adams, R. Scott Adams, Alyesha Asghar Dotson, Carrie Harris, Eric W. Iskra, Eric E. Kinder, Richard Wallace | Spilman Thomas & Battle, PLLC on 5/16/2013

In This Issue: - Notes from the Chair & Executive Editor - The Board Plays On: The NLRB Clarifies Its Position on At-Will Disclaimers - Interns This Summer? Evaluating Your Unpaid Internship Programs...more

Sixth Circuit Applies Strict Precondition of Payment Requirement to Reverse $11.1 Million FCA Judgment

by Nicholas Linder, Kirsten Mayer, Arefa Shakeel | Ropes & Gray LLP on 5/15/2013

The U.S. Court of Appeals for the Sixth Circuit, in United States ex rel. Hobbs v. MedQuest Associates, Inc., 711 F.3d 707 (6th Cir. April 1, 2013), recently reversed an $11.1 million False Claims Act (“FCA”) judgment,...more

Absent a Contract With the Provider, HMOs Are Not Liable for Unpaid Services

by Michael Klein | Sedgwick LLP on 5/10/2013

On April 19, 2013, the Texas Supreme Court handed down its opinion in Christus Health Gulf Coast, et al. v. Aetna, Inc. et al. The court’s ruling put an end to the so-called “double pay” theory of liability by downstream...more

Court of Appeal Applies Howell Rule to Future Medical Expenses and Noneconomic Damages

by Samuel Sorich | Barger & Wolen on 5/6/2013

In Howell v. Hamilton Meats & Provisions, Inc., the California Supreme Court ruled that where a plaintiff’s medical care provider, pursuant to a prior agreement with the plaintiff’s health care provider, accepted less than...more

Insurance Antitrust Legal News - May 2013 • Volume 2, Number 3

by James M. Burns | Dickinson Wright on 5/2/2013

In This Issue: - STATE EFFORTS TO RESTRICT HEALTH INSURER USE OF “MOST FAVORED NATION” CLAUSES IN PROVIDER CONTRACTS CONTINUE TO MULTIPLY: Over the last several years, several states have considered legislation...more

20 Million Reasons Why Class Action Defendants Need to Read Their Insurance Policies Closely

by Judy Selby | BakerHostetler on 4/29/2013

As previously noted in a recent blog post, defendants should immediately evaluate their insurance coverage upon receipt of a class action complaint. But as one defendant recently discovered the hard way, that evaluation must...more

Sixth Circuit in MedQuest: No FCA Liability for Violation of Medicare Conditions of Participation Without Violation of Conditions...

by Calvin Marshall | Chambliss, Bahner & Stophel, P.C. on 4/26/2013

On April 1, 2013, the U.S. Court of Appeals for the Sixth Circuit overturned an $11.1 million False Claims Act (FCA) judgment by the U.S. District Court for the Middle District of Tennessee against MedQuest Associates, Inc.,...more

Sixth Circuit Holds Physician Supervision and Enrollment Issues Are Not Conditions of Payment for Purposes of FCA Liability

by Darby C. Allen, B. Scott McBride | BakerHostetler on 4/23/2013

The Sixth Circuit Court of Appeals recently issued a decision overturning an $11.1 million False Claims Act (FCA) verdict against MedQuest Associates, Inc. (MedQuest) for submitting claims to Medicare in violation of the...more

ERISA Legal News - 1st Quarter, 2013 • Volume 4, Number 1

by Kimberly Ruppel | Dickinson Wright on 4/23/2013

In This Issue: - Supreme Court Update: Where Plan Reimbursement Or Recovery Terms Are Ambiguous Or Silent,Equitable Doctrines May Fill The Gaps: US Airways, Inc. v. McCutchen, 569 U.S. ___ (2013). In an...more

Court Rules That Supervision and Enrollment Issues Don't Give Rise to False Claims Act Liability

by Kristen Cilento Carter | Ober|Kaler on 4/19/2013

Following the ever-growing progeny of cases holding that Medicare conditions of participation do not give rise to False Claims Act (FCA) liability, the United States Court of Appeals for the Sixth Circuit overturned an $11...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

Howell Rule Applies When Medical Services Were Paid by Medicare, Court of Appeal Concludes

by Barger & Wolen on 4/12/2013

In Howell v. Hamilton Meats & Provisions, Inc. the California Supreme Court ruled that a plaintiff’s recovery of medical damages is limited to the amount paid by the plaintiff’s health insurer and accepted by the health care...more

PRRB Upholds Liquidation Requirement for Pension Expenses in Wage Index Calculation

by Mark A. Stanley | Ober|Kaler on 4/9/2013

The Provider Reimbursement Review Board (PRRB) has issued a decision upholding CMS’s policy of not recognizing pension expenses for purposes of calculating the wage index unless such expenses are liquidated within one year. ...more

Court of Appeals Rules for Government in DSH Exhausted Benefit Day Appeal

by Thomas W. Coons | Ober|Kaler on 4/5/2013

For the last several years, hospitals and the government have fought hard over where days associated with certain “dual eligible” patients should be placed in the Medicare disproportionate share hospital (DSH) calculation. At...more

Sixth Circuit Rules No FCA Liability Based on Violation of Medicare Requirements

by Ellyn L. Sternfield | Mintz Levin - Health Law on 4/4/2013

On April 1st, the Sixth Circuit reversed an $11.1 million dollar summary judgment finding entered against MedQuest Associates, a diagnostic testing company. In its opinion, the Sixth Circuit found that violation of two...more

Court Places Limits on Secretary's "No Reopening" Arguments

by Thomas W. Coons | Ober|Kaler on 3/31/2013

CMS has often argued that “base year” determinations cannot be revisited once the three-year reopening period has closed. Now, a recent decision from the U.S. Court of Appeals for the District of Columbia Circuit places those...more

Provider Reimbursement Review Board Issues Alert 9 and Revised Rules

by Jeffrey Bates, R. Michael Scarano Jr., Judith A. Waltz | Foley & Lardner LLP on 3/27/2013

On March 1, 2013, the Provider Reimbursement Review Board (PRRB or the Board) issued Alert 9, which notified interested parties that the PRRB has made revisions to its Rules and updated its Model Forms. Medicare providers...more

Claims Administrator Does Not Have to Pay Statutory Penalties for Failing to Provide Requested Documents

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

You know already that a plan administrator can be liable for statutory penalties under ERISA for failing to provide requested plan documents....more

Washington Supreme Court: Insurers May Not Reserve the Right to Seek Reimbursement of Non-covered Defense Costs

by Meredith Dishaw, William Knowles | Cozen O'Connor on 3/18/2013

The Washington Supreme Court joined a minority of jurisdictions that hold that insurers may not unilaterally reserve the right to seek reimbursement for defense costs paid in defending non-covered claims through a reservation...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

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Civil Procedure › Health Law › Insurance