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King & Spalding

CMS Releases Fifth Annual Report on Bundled Payments for Care Improvement Advanced Model

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On May 29, 2024, CMS released its fifth annual report evaluating the Bundled Payments for Care Improvement Advanced Model (BPCI Advanced Model). The BPCI Advanced Model is designed to reduce Medicare spending and maintain or...more

Mintz - Health Care Viewpoints

CMS Publishes Final Rules Implementing Part C and Part D Program Changes

On April 23, 2024, the Centers for Medicare & Medicaid Services (CMS) published final rules setting forth Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024--Remaining...more

Sheppard Mullin Richter & Hampton LLP

CMS Issues CY2025 Medicare Advantage and Part D Final Rule

On April 4, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued the contract year 2025 (CY2025) Medicare Advantage and Part D final rule (the “Final Rule”). In addition to finalizing its CY2025 proposed rule,...more

ArentFox Schiff

Health Insurers Sued Over Use of Artificial Intelligence to Deny Medical Claims

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With the surge of interest in artificial intelligence (AI), it should be no surprise that health insurers have come under scrutiny concerning their use of AI predictive tools to deny medical insurance claims. The question...more

Harris Beach PLLC

Updated Medicaid Utilization Review Regulations from NYS Department of Health

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The New York Department of Health (DOH) adopted regulations effective on September 13, 2023, that revised Medicaid Utilization Review for Medicaid fee-for-service benefits. The regulations were initially published on April...more

McDermott Will & Emery

CMS Streamlines Medicare Enrollment and Standardizes Nondiscrimination Language

In late January 2023, the Centers for Medicare and Medicaid Services (CMS) issued two updates relevant to provider and supplier organizations enrolled in Medicare: (1) a redesign to the Provider Enrollment, Chain and...more

Foley Hoag LLP - Medicaid and the Law

Medicaid and the LawFoley Hoag LLP CMS Approves Two New Medicaid Waivers to Expand Coverage, Provide Flexibilities

On September 28, 2022, the Centers for Medicare & Medicaid Services (CMS) issued approval letters for Section 1115 Medicaid demonstration applications previously submitted by Oregon and Massachusetts. Section 1115 waivers...more

Foley & Lardner LLP

Managed Care & the FCA: Are Courts Getting It Right?

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Courts are grappling with unique questions in the context of managed care programs in False Claims Act (FCA) cases. But are they getting it right? Two questions trending in courts relate to: (1) materiality under the FCA when...more

Bass, Berry & Sims PLC

OIG Approves DME Manufacturer Loan Program in Latest Advisory Opinion

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On June 23, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services published Advisory Opinion 22-13, approving an arrangement under which a durable medical equipment (DME) manufacturer...more

Roetzel & Andress

CMS’s Updated Advance Beneficiary Notice Of Noncoverage (ABN) Is In Effect

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As of January 1, 2021, providers must use the updated instructions and form Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The changes address beneficiaries who are dually enrolled in Medicare and Medicaid...more

Arnall Golden Gregory LLP

October 1, 2020 Hospice Changes: Hospices Must Provide Beneficiaries Addenda Outlining Conditions, Services, and Drugs Not Covered...

In an effort to increase coverage transparency, for hospice elections beginning on or after October 1, 2020, the beneficiary, beneficiary’s representative, non-hospice providers, or Medicare contractors may request a written...more

Seyfarth Shaw LLP

ERISA Preemption — The Courts of Appeal Continue to Rule As They Await Further Supreme Court Attempts To Define, Once and for All,...

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Synopsis: Two Courts of Appeal reach opposite results on ERISA preemption, thus continuing the judicial quest for a definitive meaning of ERISA preemption. Stay tuned for more such decisions, and yet more Supreme Court...more

Goulston & Storrs PC

Probate & Fiduciary Litigation Newsletter – October 2019

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The Probate & Fiduciary Litigation Newsletter compiles recent Trust & Estate cases. Our lawyers are at the forefront of this area of the law, shaping how it is handled in the Probate and Family Court. ...more

Proskauer - Employee Benefits & Executive...

Eighth Circuit Decision On“Cross-Plan Offsetting” Illustrates Importance Of Careful Plan Drafting

The U.S. Court of Appeals for the Eighth Circuit recently weighed in on a practice for recovering health plan overpayments known as “cross-plan offsetting.” In addition to shining a light on the controversial (but potentially...more

White and Williams LLP

Cross-Plan Offsetting to Recoup Overpayments to “Out-Of-Network” Providers Held Unreasonable

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In an opinion filed on January 15, 2019, the Eighth Circuit Court of Appeals upheld the district court’s ruling that UnitedHealth Group’s practice of recovering overpayments made to “out-of-network” providers from one plan by...more

White and Williams LLP

Purported Assignment and Power of Attorney Held Invalid in Provider’s Suit to Recover Health Benefits

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On December 4, 2018 United States District Judge Noel L. Hillman dismissed a suit for unpaid medical bills by a healthcare provider against its patient’s ERISA-governed health benefits plan, finding the assignment/power of...more

Mintz - Health Care Viewpoints

OIG Says Proposed MCO Incentive Program Protected by AKS Safe Harbor

In its favorable Advisory Opinion 18-11, the OIG explains how a managed care organization’s proposed incentive program to pay network providers to increase the amount of Early and Periodic Screening, Diagnostic, and Treatment...more

Proskauer Rose LLP

Payment by MCOs to Encourage Preventive Screenings Not a Kickback

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On October 11, 2018, the Office of the Inspector General ("OIG") for the Department of Health and Human Services ("HHS") issued an advisory opinion clarifying that an arrangement between a managed care organization and its...more

Sheppard Mullin Richter & Hampton LLP

How Broad is the Managed Care Safe Harbor?

In Advisory Opinion No. 18-11, the Department of Health and Human Services Office of the Inspector General (the “OIG”) addressed a Medicaid managed care organization’s (“MCO”) proposal to pay its contracted providers and...more

Proskauer Rose LLP

ERISA Newsletter - Second Quarter 2018

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As we head into the thick of summer, all eyes are on President Trump's nomination to the U.S. Supreme Court to replace retiring Justice Anthony Kennedy and the impact the new Justice will have on shaping the law for...more

Chambliss, Bahner & Stophel, P.C.

Seniors Often Must Fight for Medicare Home Health Benefits

Medicare is mandated to cover your home health benefits with no limit on the time you are covered. Unfortunately, few Medicare beneficiaries get the level of service they are entitled to, and many find their services cut off...more

Chambliss, Bahner & Stophel, P.C.

More States Asking to Eliminate Retroactive Medicaid Benefits

Arizona and Florida are the latest states to request a waiver from the requirement that states provide three months of retroactive Medicaid coverage to eligible Medicaid recipients. Medicaid law allows a Medicaid applicant...more

Holland & Knight LLP

Healthcare Law Update: May 2018

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Enforcement - OIG Issues Advisory Opinion on Provision of Samples by a Device Distributor - On April 30, 2018, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a...more

White and Williams LLP

Third Circuit Issues Precedential Ruling: “Anti-Assignment” Clauses in ERISA-Governed Health Insurance Plans Are Enforceable

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On May 16, 2018, the US Court of Appeals for the Third Circuit held in a precedential opinion that “anti-assignment clauses in ERISA-governed health insurance plans as a general matter are enforceable.” In so holding, the...more

K&L Gates LLP

K&L Gates Triage: ACO Improvements in the Bipartisan Budget Act of 2018 (Part 2)

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In the second segment of this two-part series discussing recent program changes introduced by the Bipartisan Budget Act of 2018 for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program...more

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