Hospitals that participate in the 340B program may be entitled to additional monies from Medicare Advantage plans in the wake of the Supreme Court’s decision in AHA v. Becerra.
In AHA v. Becerra, a unanimous Supreme Court...more
According to hospital officials in multiple states, Anthem Blue Cross is behind on billions of dollars in payments to hospitals because of new reimbursement rules, computer problems, and mishandled claims—this according to an...more
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. This performance program penalizes hospitals up to three percent of...more
Health plans are using both new and old methods to deny healthcare providers’ claims, all of which are legally and factually unsupportable. These tactics have repeatedly been rejected by arbitrators in scores of arbitrations,...more
Section 4408 of the CARES Act suspends the 2% sequestration reduction to payments under the Medicare program that have been in place since April 1, 2013. The suspension of sequestration in Medicare will run from May 1, 2020...more
The California Court of Appeal in Los Angeles recently took up the issue of whether federal and/or state law sets any rate for Medicaid MCOs to pay to hospitals for out-of-network post-stabilization services. The case was...more
UnitedHealthCare ("United") is instituting a new policy imposing a “Requirement to Use a Specialty Pharmacy Provider for Certain Medications” (“Specialty Pharmacy Policy”) that is scheduled to take effect on April 1,...more
Many contracts have provisions that state that disputes relating to the agreement will be resolved in arbitration. But often questions arise as to whether a particular dispute should be decided in arbitration or in court. ...more
This article discussed legislation that was until recently pending in California (AB 1611) and that was intended to prevent patients from receiving “surprise” bills from out of network hospitals after the patients receive...more
Under the Employee Retirement Income Security Act (“ERISA”), health care providers can file legal actions to recover employee benefits if they obtain a proper assignment of the patient’s benefits. Increasingly, however, ERISA...more
Health plans and their delegated IPAs are using a number of different tactics to deny payment for inpatient services by improperly classifying inpatient claims as observation or other types of outpatient status. Payers are...more
8/19/2019
/ Centers for Medicare & Medicaid Services (CMS) ,
Class Action ,
Constitutional Challenges ,
Department of Health and Human Services (HHS) ,
Health Insurance ,
Hospitals ,
Inpatient Billing ,
Managed Care Contracts ,
Medi-Cal ,
Medicare ,
Medicare Part A ,
Medicare Part B ,
Two-Midnight Rule ,
Underpayment
Health Plans’ Use of Policies and Guidelines to Reduce Coverage and Reimbursement -
A technique we have seen payers use more commonly in recent months than in the past is to unilaterally implement policies or “clinical...more