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
On July 26, 2022, LifeNet was granted summary judgment in its challenge to portions of the second set of implementing regulations for the Independent Dispute Resolution (IDR) process for air ambulance providers under the No...more
8/4/2022
/ Administrative Procedure Act ,
Appeals ,
Arbitration ,
Department of Health and Human Services (HHS) ,
Dispute Resolution ,
OMB ,
Out of Network Provider ,
Summary Judgment ,
Surprise Medical Bills ,
Texas ,
Vacated
A jury last week awarded TeamHealth $60 million in punitive damages and late last month awarded TeamHealth $2.65 million in compensatory damages against UnitedHealthcare for underpaying TeamHealth affiliates for...more
As we reported in our Managed Care Newsletter in April 2020, the CARES Act passed by Congress last year provides for a 20% increase to the DRG weights in the Medicare Inpatient Prospective Payment system (“IPPS”) for patients...more
Some health plans are trying to improperly reduce reimbursement owed to providers for services related to COVID-19 by unilaterally carving out those services from existing provider contracts – e.g., Aetna, certain Blues, etc....more
Several health plans have announced that for certain services related to COVID-19 they are waiving patient financial responsibility – e.g., copays, coinsurance, deductibles, etc. The federal government has encouraged these...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
Hospitals that attempt to discharge a patient to a post-acute level of care but are not able to because they cannot find an appropriate accepting facility must continue providing care if the patient cannot be safely...more
12/16/2019
/ Acute Facilities ,
Affordable Care Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Health Insurance ,
Health Insurance Exchanges ,
Hospitals ,
Knox Keene ,
Medicaid ,
Medicare ,
Medicare Advantage ,
Medicare Provider Agreements ,
Qualified Health Plans
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
Payers are increasingly establishing purported “site of service” policies and guidelines that restrict the circumstances under which members may obtain certain services at hospital outpatient departments (HOPDs). In the...more