Over the past 16 months, three of the nation’s largest commercial payers – UnitedHealthcare, Anthem and CIGNA – have instituted new policies affecting how and whether they will pay for high-cost drugs administered in hospital...more
On December 4, 2019, the American Hospital Association and several hospital associations and hospitals (“Plaintiffs”) filed suit against the Secretary of Health and Human Services (“HHS”) to challenge the Centers for Medicare...more
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
12/13/2019
/ Affordable Care Act ,
Department of Labor (DOL) ,
Employer Group Health Plans ,
Health Care Providers ,
Health Insurance ,
Out-of-Pocket Expenses ,
Pricing ,
Public Health Service Act ,
Regulatory Standards ,
TPAs ,
Uniform Commercial Code (UCC)
On January 15, 2019, the United States Court of Appeals for the Eighth Circuit considered whether certain plan documents allowed UnitedHealth Group Inc. and affiliates (“United”) to engage in a practice known as “cross-plan...more
On December 12, 2018, Aurora Health Care (Aurora), a Wisconsin-based healthcare system, entered into a settlement agreement with the United States and the State of Wisconsin to pay $12 million to resolve allegations that...more
The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS) recently released its annual publication identifying the top management and performance challenges facing HHS. In the 2018...more
On October 10, 2018, Senate Judiciary Chairman Chuck Grassley, R-Iowa, urged the Chairman of the Federal Trade Commission (FTC) to conduct an assessment of potentially anti-competitive provisions in contracts between...more
On July 3, 2018, the U.S. District Court for the Northern District of Illinois issued a ruling dismissing Advocate Christ Medical Center (ACMC) from a False Claims Act suit brought by a former resident against ACMC and a...more
On June 12, 2018, the United States Court of Appeals for the Fifth Circuit issued a ruling in Innova Hospital San Antonio, L.P. v. Blue Cross and Blue Shield of Georgia, Inc., et al. that clarified the scope of what a...more
On May 14, 2018, the U.S. Attorney’s Office for the Southern District of Texas announced that Memorial Hermann Health System (MHHS) will pay $1,929,071.38 to resolve allegations that it improperly billed government healthcare...more
Courts are continuing to grapple with whether relators can use statistical sampling to prove liability in False Claims Act (FCA) cases. As demonstrated by two recent cases, courts remain skeptical that relators can meet...more
On November 2, 2017, CMS issued a Final Rule that updates payment policies, payment rates, and quality provisions under the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2018. In addition to establishing...more
On September 26, 2017, the Senate passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. The CHRONIC Care Act amends Title XVIII (Medicare) of the Social Security Act...more
On August 28, 2017, the United States District Court for the Eastern District of Michigan held that a provider must fully exhaust administrative remedies before it can seek a remedy in Federal court against a Medicare...more
On August 2, 2017, CMS issued the Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Final Rule (Final Rule) that updates...more
On June 30, 2017, the Government Accountability Office (GAO) released a report on the Hospital Value-Based Purchasing (HVBP) program, which evaluates hospital performance on quality and efficiency measures, and provides...more
On June 9, 2017, the United States Court of Appeals for the Seventh Circuit affirmed the lower court’s grant of summary judgment in Methodist Health Services Corp. v. OSF Healthcare System d/b/a Saint Francis Medical Center,...more
On May 18, 2017, the Senate Finance Committee passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, a bipartisan bill focused on improving care for chronically ill...more
On April 11, 2017, the American Association of Nurse Anesthetists (AANA), an organization representing more than 50,000 Certified Registered Nurse Anesthetists (CRNAs), filed a complaint for declaratory and injunctive relief...more
On January 12, 2017, the HHS OIG issued its final rule amending regulations relating to its authority under the Affordable Care Act (ACA) to exclude individuals and entities from participation in federal healthcare programs....more
On December 15, 2016, HHS announced an Accountable Care Organization (ACO) initiative for beneficiaries who are dually eligible for Medicare and Medicaid. The Medicare-Medicaid ACO Model (Model) builds on the Medicare Shared...more
On November 17, 2016, the U.S. Surgeon General released a comprehensive report on addiction, substance misuse, and substance use disorders. The Surgeon General’s Report on Alcohol, Drugs, and Health is considered a landmark...more