Medical Reimbursement

News & Analysis as of

Supreme Court to Hear Arguments Involving a Health Plan’s Right to Recover Plan Overpayments

While public attention is currently focused on the upcoming high profile Supreme Court decision in King v. Burwell (which involves subsidies for exchange-based coverage under the ACA), the Supreme Court recently decided to...more

Supreme Court Blocks Provider Challenges to Medicaid Program

On March 31, 2015, the Supreme Court issued the first of several expected decisions that will impact the healthcare industry this year, ruling that Medicaid providers have no constitutional or statutory right to challenge a...more

In Pursuit of Benefit Plan Overpayments

Benefit overpayments can (and often do) result from pension calculation errors that inflate a participant’s lump sum distribution or monthly pension payment. Overpayment scenarios are common in the disability and group health...more

Supreme Court Says Private Health Care Providers Cannot Sue to Force State of Idaho to Raise Its Medicaid Reimbursement Rates

In Armstrong v. Exceptional Child Center, Inc., Case No. 14-15, issued March 31, 2015, the United States Supreme Court ruled that a group of private health care providers could not sue officials in Idaho’s Department of...more

ERISA: Supreme Court to Determine Whether Money is Fungible…When it Comes to Recovery of Overpayments from ERISA Beneficiaries

When it comes to recovery of overpayments from ERISA beneficiaries… money is a fungible commodity in the Eleventh Circuit, but is not a fungible commodity in the Ninth Circuit....more

Breaking News - Reinforcement For Buckman

We’ve been watching for Armstrong v. Exceptional Child Center, Inc., ___ U.S. ___, 2015 WL 14194231 (U.S. Mar. 31, 2015), ever since we spotted an intriguing footnote mentioning the certiorari grant in Ouellette v. Mills, ___...more

Manatt on Health Reform: Weekly Highlights - March 2015 #5

This week, Medicaid expansion gains traction in Montana, California submits its waiver application to renew DSRIP and to propose several new delivery system transformation and alignment initiatives, and the Supreme Court...more

Colorado Passes “Full Parity” Telemedicine Law, Although Some Gaps Remain

On March 20, 2015, Colorado Governor John Hickenlooper signed into law HB 15-1029, which requires that insurers operating in Colorado reimburse health care providers for telehealth services in all of Colorado’s counties,...more

Telehealth Bill Moving Forward in Florida-But Medicaid Coverage Sacrificed

Last week, the Florida Senate Health Policy Committee removed language from proposed telehealth legislation that would require Medicaid reimbursement for telemedicine services at the same rates as face-to-face examinations....more

Who Decides When Medicaid Payment Rates Are Not Enough?

In 2005, the Florida Pediatric Society, the Florida Association of Pediatric Dentists, and a number of parents and guardians on behalf of their individual children in the Medicaid program brought suit against the state of...more

Eleventh Circuit Enforces Subrogation Clause

The Eleventh Circuit recently concluded that Robert Montanile, a welfare plan participant, could not avoid reimbursing the National Elevator Industry Health Benefit Plan for benefits it paid on his behalf after he recovered...more

Blurring the Lines between False Claims Act Litigation and Putative Federal Malpractice Law: The DOJ Quietly Invokes “Worthless...

On October 10, 2014, the United States Department of Justice (“DOJ”) announced a civil settlement agreement (the “Settlement”) with Extendicare Heath Services, Inc. and its subsidiary Progress Step Corporation (collectively,...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

Healthcare Providers Face Increasing Financial Pressure and Bankruptcy Risk

The health of the healthcare industry can be summarized as follows: as go federal reimbursement rates, so goes the financial viability of healthcare providers, whether hospitals, nursing homes or medical practices. These...more

Top 5 takeaways on telemedicine and eHealth

Here are the main legal topics on telemedicine and eHealth discussed during the ETSI eHealth Workshop on telemedicine where I gave a speech on the legal implications of telemedicine. The Workshop was very interesting...more

New Development Regarding Medicaid STAR+PLUS Network Provider Agreements for Texas Nursing Homes

Beginning this fall, Texas nursing home reimbursement will be converted to Medicaid Managed Care. In preparation for the Medicaid Managed Care rollout, Texas Managed Care Organizations ("MCOs") recently sent out network...more

Never Fear Regulatory Violations – Focus on Conditions to Payment

The U.S. Court of Appeals for the Fourth Circuit recently upheld the dismissal of a False Claims Act (FCA) suit against Omnicare, Inc., in which the relator alleged that certain drugs repackaged by Omnicare’s subsidiary were...more

Plan C for Your Plan B - Using Excepted Benefits to Maximize Cost Savings under Obamacare for Small Businesses: Non-Coordinated...

Overview - The Godfather trilogy is one of my favorite movie series. My mother was Italian American with both parents from the Old Country. What is the connection between these Oscar winning films and Obamacare?...more

Medicare Contractors Receive CMS Direction Regarding Recalcitrant Providers

CMS recently issued a transmittal providing guidance to Medicare program contractors on when and how to refer certain “recalcitrant providers” to CMS for potential sanctions under the Office of Inspector General’s (OIG) civil...more

Modification of “Use It or Lose It” Rule for Health Flexible Spending Arrangements

The Internal Revenue Service recently issued new guidance modifying the “use it or lose it” rule applicable to health flexible spending arrangements (FSAs) to allow carryover of certain unused health FSA amounts into the next...more

Court Sides With CMS Stark Regulations on Physician-Owned Under Arrangement Service Providers

On May 24, the U.S. District Court for the District of Columbia in Council for Urological Interests v. Sebelius1 (‘‘CUI’’) sided with the Centers for Medicare & Medicaid Services in a lawsuit brought by a group of urologists...more

Expanding Access to, and Development of, Personalized Medicine

In a July 8th, 2013 letter to the Centers for Medicare & Medicaid Services (CMS), the Personalized Medicine Coalition (PMC) advised that proposed reimbursement schedules for diagnostic medicine will threaten the development...more

Doctors Going To Jail: Criminal Prosecutions For Quality Of Care And Fraud

When I was growing up (and probably for generations), every proud parent wanted their son or daughter to go to medical school....more

Managing Peer Review Investigations: How to Avoid Hearings and Litigation

In this presentation: - Provide recommendations regarding best practices, bylaw provisions and other strategies to address and resolve quality and peer review issues without resorting to “investigations” and...more

Health Care Reform Blog: IRS Proposes Additional Minimum Value Rules

Last Friday the IRS released additional proposed regulations implementing the minimum value requirement for coverage sponsored by employers with 50 or more FTEs. The proposed rules provide that amounts contributed by...more

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