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The Transition to Value-Based Health Care: A View from Washington of President Trump’s First 60 Days

“A View from Washington of President Trump’s First 60 Days,” the inaugural segment of our value-based health care teleconference series, was hosted by Thomas Bulleit, who heads the Ropes & Gray health care practice in the...more

Trumpcare’s hit on the poor also would steal benefits from the middle-class elderly

Republicans have long fumed about the federal government’s role in health care, ever since Medicare for the elderly and Medicaid for the poor were both passed in 1965. Now, though, we’re at a crossroads, where a frontal...more

Justice Department Joins Whistleblower Suit Accusing UnitedHealth Group of Overcharging Medicare by “Hundreds of Millions”

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit, United States of America ex rel Benjamin Poehling v. Unitedhealth Group Inc., No. 16-08697 (Cent. Dist. Cal. Sep. 17, 2010), ECF No. 79, against...more

Insurers’ Suit Against Government for Affordable Care Act Payments May Proceed; If Successful, Insurers Entitled to Billions from...

In a closely watched case, the Court of Federal Claims last week refused to dismiss a health insurer’s putative class action against the Federal government for payments authorized under the Affordable Care Act. The Court’s...more

Indiana Supreme Court Extends the Stanley Doctrine to State-Sponsored Medical Reimbursements

On October 21, 2016, the Indiana Supreme Court weighed-in on a closely watched case that drew much attention from the defense and plaintiff’s bar alike. Approximately one (1) year ago, I reported that the Indiana Court of...more

Nondiscrimination Standards Under ACA Section 1557: Now Is the Time to Act

Health insurers and group health plan sponsors must closely review the final rule titled “Nondiscrimination in Health Programs and Activities” (“Final Rule”) implementing Section 1557 of the Affordable Care Act (“ACA”) that...more

False Claims Act Penalties Moving Full Steam Ahead

By August 1, 2016, all federal agencies must adjust their civil monetary penalties, including penalties required by the False Claims Act (“FCA”), to account for inflation. Last month, the Railroad Retirement Board, which...more

House v. Burwell: Insurer Cost-Sharing Subsidies Unauthorized

A U.S. District Judge has ruled that HHS unlawfully has spent billions of dollars to reimburse insurers for cost-sharing reductions granted to individuals who bought health insurance through an ACA Exchange such as...more

IRS Denial of Section 501(c)(3) Status for a Commercial ACO

The IRS recently released a ruling, Private Letter Ruling (“PLR”) 201615022, denying Section 501(c)(3) tax-exempt status to a “commercial” accountable care organization (“ACO”). This is the IRS’ first published guidance...more

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged...more

A&B Healthcare Week in Review

I. REGULATIONS, NOTICES, & GUIDANCE - On April 15, 2016, the Food and Drug Administration (FDA) issued a proposed rule entitled, “Applications for Approval and Combinations of Active Ingredients Under Consideration for...more

IREG Update - Department of Health and Human Services and the Centers for Medicare and Medicaid Services take action to change the...

Department of Health and Human Services and the Centers for Medicare and Medicaid Services take action to change the risk adjustment methodology - In February, we wrote about the controversial effect of the federal risk...more

Final Rule on refund of Medicare overpayments: Key requirements to know

The long awaited Final Rule on return of Medicare overpayments (Final Rule) issued by the Centers for Medicare & Medicaid Services (CMS) took effect on March 14, 2016. The Final Rule applies to Medicare Part A and Part B...more

Compliance With Medicare Secondary Payer Act At Issue In Auto Insurance Case

A recent decision in the District of New Jersey addressed an auto insurer’s obligations to comply with the Medicare Secondary Payer Act. Auto insurers may wish to review their practices and procedures in light of this...more

Whether Naughty or Nice, Recovery Audit Contractors Are Coming to Medicare Advantage

During the holiday season lull, the Centers for Medicare and Medicaid Services (CMS) issued a weighty document. The agency put out a draft statement of work to procure Recovery Audit Contractors (RACs) for the Medicare...more

A New Arrow in the Quiver for Physicians Facing Dual Civil and Criminal Fraud Investigations

At a time when doctors face increased pressure from competition, reduced fee schedules, and greater scrutiny from insurance company Special Investigative Units (“SIUs”) and State Office of Insurance Fraud Prosecutors...more

Manatt on Health Reform: Weekly Highlights - October 2015 #2

Iowa's largest insurer joins the State's Marketplace for coverage year 2017; carrier changes are announced for Marketplaces in Kentucky, Oklahoma and Wyoming; and South Dakota's Governor convenes the Health Care Solutions...more

Health Update - September 2015

Latest Healthcare False Claims Act Roundup and Top 3 Best Practices to Reduce Exposure - As the legal landscape in healthcare becomes increasingly complex, healthcare companies that receive federal program funds face...more

Hospitals Accused of Violating the False Claims Act Through Ownership of the PPO For Their Self-Funded Employee Health Plans

On August 27, 2015, following notification by the government that it had decided not to intervene, the United States District Court for the Middle District of North Carolina, ordered that a qui tam complaint charging...more

Connecticut to Tighten Data Privacy Requirements

On June 1, 2015, the Connecticut Legislature passed S.B. 949, a comprehensive data privacy and security bill that tightens the state’s data breach response requirements and imposes new obligations on state contractors and the...more

Blog: Senator Grassley Requests Information Related to Potential Medicare Advantage Fraud

Senator Grassley issued letters this week to the Centers for Medicare and Medicaid Services (CMS) and Department of Justice (DOJ) related to potential fraud in the Medicare Advantage program. Citing news articles, DOJ...more

California’s Insurance Fraud Prevention Act: 3 unsettled issues the health sector should understand

California’s Insurance Frauds Prevention Act, Ins. Code §§ 1871 et seq. (IFPA), is an unusual false claims statute. It allows “interested persons” (aka whistleblowers or relators) to file false claims lawsuits based on the...more

Orthopedic Patient Doesn’t Have a Leg to Stand On

It’s well known that Medicare, Medicaid and commercial insurers hate the ever-increasing trend of hospitals buying facilities and practices and then charging provider-based (i.e., higher) rates than the facilities and...more

A Cautionary Tale for Companies With Potential False Claims Act Exposure

A False Claims Act suit can be a company’s worst nightmare, as it may potentially result in large settlements and awards on account of the statute’s trebled damages provision. However, the nightmare for AmerisourceBergen was...more

HealthCare Fraud and Courtesies: What to Know Before Waiving a Copayment

Many healthcare facilities and physicians waive the insurance copayment for physicians and their families (known as professional courtesy) or other patients. Yet, despite how prevalent the practice is and the limited...more

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