Reimbursements

News & Analysis as of

Failure to Disclose Best Pricing: Pharmaceutical Companies Settle FCA Claims for $784 Million

The Department of Justice announced late last month that pharmaceutical manufacturers Wyeth and Pfizer would pay $784 million to resolve a False Claims Act investigation and qui tam lawsuit arising from Wyeth’s failure to...more

Insurance Antitrust Newsletter - May 2016

Insurer Antitrust Exemption in Europe in Jeopardy - In the United States, the McCarran Ferguson Act provides insurers with an exemption from the federal antitrust laws. Enacted in 1945, the Act provides that conduct that...more

After New York, Florida Curbs Surprise Bills for Emergency and Out-of-Network Services

It is generally understood that if a managed care member utilizes the services of a non-participating provider, the member could incur significant out of pocket expenses. However, there are instances where a member may...more

According to the Right and Good of Ancient Law

“You don’t know what you don’t know” is a popular catchphrase. So, do you know what a “betterment” is and how the law of betterments operates? Land use law has ancient roots. Sometimes, a case requires an appellate...more

SCOTUS Oral Argument Suggests FCA Implied Certification Theory Is Here to Stay – But Perhaps with Limits

Oral argument in Universal Health indicates Justices disinclined to categorically reject False Claims Act implied certification theory, though may limit its scope. On April 19, 2016, the United States Supreme Court heard...more

Supremes Hear Argument on Implied Certification Theory

On April 19 the U.S. Supreme Court heard oral argument in Universal Health Services v. U.S. ex rel. Escobar. That’s the case in which the First Circuit upheld a whistleblower suit brought against a mental health clinic that...more

The California Edition of the Employment & Labor Newsletter

Take a Seat! California Supreme Court Provides Clarity on California’s Suitable Seating Laws - A recent ruling by the California Supreme Court on suitable workplace seating arrangements will affect a vast number of...more

FHA Announces Final Revisions to Loan-Level Certification Form

On March 15, 2016, the Federal Housing Administration (FHA) announced final changes to its loan-level certification form, 92900-A HUD/VA Addendum to the Uniform Residential Loan Application. The announcement represents...more

Smooth Operators: Seventh Circuit Untangles Objections and Affirms Settlement of Hair Product Class

The Seventh Circuit Court of Appeals affirmed a class settlement over objection in a case involving a hair-smoothing product (“the Smoothing Kit”) that allegedly destroyed users’ hair and burned their scalps. Plaintiffs sued...more

What’s In a Name? Not Much, Says Colo. Federal Court

On March 31 a federal court in Colorado threw out a suit by 80 chiropractors against several national health insurers. The chiropractors alleged that the insurers violated Colorado law by paying them less than physicians and...more

The ERISA Litigation Newsletter - March 2016

Editor’s Overview - This month we review the U.S. Supreme Court’s decision in Montanile v. Board of Trustees of National Elevator Industries Health Benefit Plan where the Supreme Court considered the scope of...more

Time to Review Plan Subrogation Procedures, Part 2

I blogged a few days ago about the U.S. Supreme Court decision making it harder for plans to recover from a third-party settlement fund for the amount the plan paid when a participant is injured by that third-party. A recent...more

Enforcing Pay-to-Play Violations

I recently had an interesting dialogue with a city attorney in a pay-to-pay state about a new and – from the perspective of candidates everywhere – concerning state trend in pay-to-pay enforcement: mandatory candidate...more

Supreme Court to Hear False Claims Act "Implied Certification" Appeal

The U.S. Supreme Court will hear oral argument on April 19, 2016, in United Health Services v. United States ex rel. Escobar, No. 15-7, a case likely to resolve the current split among federal appellate courts on the...more

U.S. Supreme Court’s Upcoming Ruling on False Claims Act Case May Have Major Impact on Government Contractors

The U.S. Supreme Court is set to hear oral arguments next month in a False Claims Act (“FCA”) case that could significantly broaden the scope of the statute and resolve a split among the U.S. Circuit Courts. If the Supreme...more

Florida Passes New Telehealth Bill: Focus is Reimbursement

After several hard-fought years of unsuccessful attempts, the Florida Legislature on Friday passed a new bill designed to set the stage for telehealth commercial insurance coverage in the Sunshine State. This is a great step...more

California Employment Law Notes - March 2016

Nuclear Plant Maintenance Manager's Whistleblower Claim Was Properly Dismissed - Sanders v. Energy Northwest, 2016 WL 560809 (9th Cir. 2016) - David W. Sanders, a maintenance manager for Energy Northwest (a...more

Supreme Court Rules Employee Benefit Plan Out of Luck Once Settlement Funds Are Spent on Nontraceable Items

The U.S. Supreme Court in Montanile v. Bd. of Trs. of Nat. Elevator Indus. Health Benefit Plan, U.S., No. 14-723, 1/20/2016,considered what happens when a participant in an employee benefits plan under the Employee Retirement...more

3 Things to Consider When Dealing with Bundled Payments to Providers

The Centers for Medicare & Medicaid Services (CMS) has traditionally paid health care providers separately for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This...more

Illinois Telemedicine Rules: Licensing, Practice, Payment

Illinois is experiencing growth in telemedicine and telehealth offerings available to patients in the Prairie State. Historically, Illinois telehealth services have been more limited to hospital and institutional settings,...more

2016 Is Ramping Up For Telemedicine Developments

Two months in and this year has already seen significant movement in regulatory action across the country to expand the ability to provide telemedicine services. Below please find some of the more significant items that have...more

Money, Money, Money...Must Be Funny...in the Employee Training World

Score one for the employers this year: An appellate court decision issued last month determined that an employee who chooses to partake in the employer’s voluntary training program is required to reimburse the employer...more

Not So Fast: Employers Must Reimburse for Miles and Other Business Expenses Incurred By Employees

From parachuting into a remote location in Azerbaijan to jumping skyscrapers in Abu Dhabi to drone dodging in the streets of Los Angeles, the latest Fast and Furious movie was captivating from start to end. Who doesn’t want...more

Initial residency period (IRP) issues (Part II): What happens when a resident trains longer than expected?

The Medicare program reimburses a higher proportion of a hospital’s per-resident direct graduate medical education (DGME) training costs for the limited period of time required for each resident to become board-certified in...more

Supreme Court Says No Subrogation Claims from Health Plan After Participant Spends Settlement

On January 20, the Supreme Court released its decision in Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan, concluding that although health plan fiduciaries can generally seek subrogation...more

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