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OIG Issues Favorable Advisory Opinion on Telehealth Marketplace MSO-PC Arrangement

The Department of Health and Human Services, Office of Inspector General (OIG) recently issued a favorable advisory opinion under the federal Anti-Kickback Statute (AKS), wading into the world of not only telehealth but also...more

GAO Report Gives MA Organizations and Behavioral Health Providers Food for Thought on Prior Authorization

The US Government Accountability Office (GAO) recently released a report on the Centers for Medicare and Medicaid Services (CMS)’s oversight of prior authorization criteria for behavioral health services (BHS) by Medicare...more

Lawsuit Over AI Usage by Medicare Advantage Plans Allowed to Proceed

The US District Court for the District of Minnesota has ruled that plaintiffs may proceed in a putative class action lawsuit brought against a Medicare Advantage organization (MAO) to challenge its alleged use of an...more

CMS Releases New Proposed Rule for Medicare Advantage and Part D

On December 10, 2024, the Centers for Medicare and Medicaid Services (CMS) released a Proposed Rule for revisions to the regulations governing the Medicare Advantage (MA) program, Medicare Prescription Benefit (Part D),...more

New York issues extensive new pharmacy benefit manager regulations

On November 27, 2024, the New York State Department of Financial Services (DFS) will be releasing new regulations governing pharmacy benefit managers (PBMs). Beginning with legislation in 2021, New York has been active in...more

California Implements New AI and Software Regulations for Insurers

On September 28, 2024, California enacted SB 1120, which regulates the use of artificial intelligence (AI), an algorithm, or “other software tool” in utilization review and utilization management (UR/UM) functions by...more

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