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Managed Care Quarterly Review: Issue 1

Tips for Managing Large Claims Disputes Part 1: Pre-Litigation Avoidance and Early Litigation Strategies - Large claims disputes brought by providers against payers are on the rise. Based on previous experience with dozens...more

Dealing With the ‘AR Dump’: Don’t Accept the Spreadsheet

“AR dump” cases involving thousands of medical claims are on the rise. The standard playbook is for the provider to run its accounts receivable report and file a summary complaint or arbitration demand alleging the total...more

First Circuit Finds that the Allegations in Escobar Satisfy the Supreme Court’s Materiality Requirements

The United States Supreme Court’s landmark decision in Escobar, which we have discussed previously, upheld the use of the implied certification theory where the implied certification of statutory/regulatory compliance is...more

Seventh Circuit Finds that Pharmacy Discount Programs Are Not Exempt from the Definition of “Usual and Customary”

Created in 2006, Medicare Part D is a government program that subsidizes the cost of prescription drugs to Medicare beneficiaries. The program is run through “Plan Sponsors” – private entities that receive a fixed monthly...more

6/3/2016  /  CMS , Kmart , Medicare Part D , Pharmacies , Qui Tam

Third Circuit Ruling Reflects the Narrowed Scope of the Public Disclosure Bar under the Affordable Care Act

The public disclosure bar is a statutorily created hurdle that plaintiffs must cross to successfully maintain a False Claims Act suit. The principle was originally enacted to prevent individuals from filing “parasitic” False...more

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