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Medicare Advantage Payors Have Not Redressed 340B Underpayments

CMS recently published its remedy in response to the Supreme Court’s decision that CMS’s 340B outpatient drug payment policy violated the Medicare statute. Many hospitals that are 340B covered entities will now receive tens...more

New Medicare Advantage Regulations Add Provider and Beneficiary Protections Against Plan Utilization Management Policies

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a Final Rule (CMS-4201-F) regarding the Medicare Advantage (MA) and Part D programs. The Final Rule includes changes related to various aspects of...more

Supreme Court Ruling in AHA v. Becerra May Affect 340B Hospitals' Reimbursement Rights Against Medicare Advantage Plans

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

Impacts of United's Recent Strategic Terminations and Emergence as a Provider on the Healthcare Marketplace

UnitedHealthcare ("United"), the nation’s largest health insurer, is using a dual strategy to put downward pressure on provider reimbursement rates: (1) strategic contract terminations, combined with (2) heavy investment in...more

CMS Releases Section 1135 Waiver in Response to the Novel Coronavirus Pandemic

On March 13, 2020, President Trump declared the coronavirus pandemic a national emergency, invoking powers under the National Emergency Act and the Stafford Act. The President’s declaration, coupled with Secretary Azar’s...more

Strategies for Addressing Reference-Based Plans

The move by some employer plans to a “reference-based” pricing model has created a need for healthcare providers to develop a strategy to confront payment challenges that these plans create. A prevalent model of...more

Recent Health Plan Practices That Are Resulting in Underpayments to Providers

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

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