Health Maintenance Organizations

News & Analysis as of

PPOs and Other Non-HMO Products Now Require Approval and Periodic Reviews of Network Adequacy in New York

The New York Legislature recently enacted legislation that will require all health insurance plans that issue policies that provide for the use of a provider network to obtain network adequacy certification. The new...more

View From McDermott: A New Type of ERISA-Based Hold-Up—The Rise of Out-of-Network Provider Suits Against Self-Funded Health Care...

Over the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organization (‘‘HMO’’) networks and attempted to...more

DC Circuit Dismisses Appeal By Three Hospitals Challenging Subcontractor Status

On November 14, 2014, the United States Court of Appeals for the District of Columbia dismissed as moot an appeal by three hospitals affiliated with the University of Pittsburgh Medical Center. The hospitals had challenged...more

Recent Developments in PA and NJ Regarding Scope of Privilege for Health Care Facilities Engaged in Peer Reviews and Self-Critical...

Three recent cases offer guidance to health care entities in Pennsylvania and New Jersey regarding the discovery of documents created in connection with peer reviews, quality of care reviews and adverse event investigations...more

New York’s “Emergency Medical Services and Surprise Bills” Law

Earlier this year, the New York Legislature enacted, and Governor Cuomo signed, legislation that will impact billing and reimbursement for some out-of-network health care services, require new disclosures from providers...more

MoFo New York Tax Insights - Volume 5, Issue 9 - September 2014

In This Issue: - ALJ Upholds Denial of Sales Tax Refund Because Vendor Failed to First Make Refunds to Customers - HMO Held Exempt from New York City General Corporation Tax - State Tax Department Issues...more

Resistance WAS Futile—California Conforms to ACA Waiting Period Requirement

After wandering in the wilderness for a year, California has now come in from the cold and conformed its requirements for eligibility waiting periods to the federal standard adopted in the Affordable Care Act (ACA). Effective...more

New ACA Rules Could Require Broader Provider Networks

"If you like your doctor, you can keep your doctor." President Obama repeated this assurance to the American public numerous times, and the statement was prominently featured on the White House web site prior to and after...more

Favorable Ruling: Taxability of HMOs Under New York City General Corporation Tax

A New York City Tax Appeals Tribunal Administrative Law Judge (ALJ) recently ruled in favor of Aetna, Inc. (Aetna) on whether a health maintenance organization (HMO) was “doing an insurance business” in New York State,...more

News from the Health Law Gurus™: May 2014

News from the Health Law Gurus™ is a weekly summary of notable health law news from around the country with helpful links to related content. ...more

The Check’s in the Mail - Who Is Responsible for Payment in a Delegated-Network System?

In today’s healthcare system, reimbursement issues involve not only prompt pay statutory provisions but also various risk-shifting arrangements included in a delegated-network system of managed care. When the insolvency of...more

Medicaid Regional Care Organizations – Turning The Clock Back Twenty Years

Physicians who were practicing in the 1990s were involved in numerous attempts to organize themselves in order to be able to participate in and even financially survive the onslaught of managed care delivery systems. The new...more

California Supreme Court Rejects Erosion of One Final Judgment Rule: "Final Means Final"

On October 3, 2013, the California Supreme Court handed down its opinion in Kurwa v. Kislinger, S201619, confirming that under settled California practice, as codified in Code of Civil Procedure section 904.1(a), to be...more

Defendants Must Keep Insurance Coverage Considerations in Mind When Settling Class Action Lawsuits

On July 18, 2013, a Pennsylvania appellate court held that class action defendant Cigna Corporation (Cigna) was not entitled to insurance coverage for any part of a settlement it paid to plaintiffs because Cigna did not...more

Court rules employers who provide services to federal government employees subject to federal contracting regulations

A federal court recently ruled that hospitals affiliated with the University of Pittsburgh Medical Center became “federal subcontractors” when they entered into contracts with an HMO that provided health services for federal...more

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

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

Capitol Report: Bill To Implement And Enforce The Patient Protection And Affordable Care Act’s Requirements Applicable To Health...

Committee Substitute for Senate Bill 1842 (CS/SB 1842), passed by the 2013 Florida Legislature, enacts changes to the Florida Insurance Code (the “Code”). These changes are necessary to implement and enforce requirements of...more

Playing Cards With a Government That Stacks the Deck - D.C. District Court Radically Expands The "Christian Doctrine" To...

On March 30, 2013, the U.S. District Court for the District of Columbia issued a decision imposing certain socio-economic contract requirements on subcontractors operating hospitals associated with the University of...more

OFCCP Enforcement Powers Expanded Over Healthcare Industry

In a case closely monitored by the healthcare industry, a recent decision from the United States District Court for the District of Columbia expanded the jurisdiction of the Office of Federal Contract Compliance Programs...more

Hospitals Face Mandatory Affirmative Action Obligations Incorporated by Operation of Law Into Their Federal Subcontracts

In UPMC Braddock v. Harris, the U.S. District Court for the District of Columbia upheld the U.S. Department of Labor’s Arbitration Review Board decision treating hospitals as government subcontractors subject to the equal...more

Court Ruling May Subject Hospitals and Health Care Providers to OFCCP Regulation

Hospitals, health care providers, and managers of other businesses across the country may be surprised to learn that under a new federal court ruling, their organizations may now qualify as government contractors or...more

Health Care Providers Beware — You May Be a Governmental Contractor

Executive Order 11246 (Order) was first issued in September 1965 by President Johnson. Its purpose was to prohibit race, religion, color, and national origin discrimination by federal contractors and subcontractors and...more

Hospitals that Provide Services to Government Employees Through an HMO are Government Contractors, Court Rules

Healthcare providers who treat government employees through a health maintenance organization are government subcontractors subject to the jurisdiction of the Office of Federal Contract Compliance Programs (OFCCP), according...more

Health Care Services Providers to Federal Health Plan Members Subject to Federal Affirmative Action Compliance Audit

On March 30, the US District Court for the District of Columbia held that three University of Pittsburgh Medical Center-affiliated hospitals were federal subcontractors to an HMO that provided a managed care health plan to...more

Federal District Court Affirms U.S. Department of Labor's Position that Healthcare Providers Participating in HMOs for Federal...

In a long-awaited decision, the U.S. District Court for the District of Columbia ruled that three hospitals that provide medical services through a Health Maintenance Organization (HMO) to individuals covered by the Federal...more

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