In a decision important to health care payors and providers alike, a California Court of Appeal, in AToN Center, Inc. v. United Healthcare Insurance Company, et al., 93 Cal.App.5th 1214 (2023), agreed with a lower court...more
Over the past few years, there has been tightening enforcement and numerous lawsuits driven by the increasingly complex web of federal and state anti-kickback and anti-inducement statutes. In a new CLE-eligible webinar,...more
9/26/2023
/ Anti-Kickback Statute ,
Continuing Legal Education ,
Defense Strategies ,
Enforcement Actions ,
Fraud Abuse and Waste ,
Fraud Prevention ,
Health Care Providers ,
Health Plan Sponsors ,
Healthcare Fraud ,
Inducement ,
Physicians ,
Webinars
On November 4 and 7, 2022, the California Department of Managed Health Care (DMHC) issued two All Plan Letters (APL 22-026 and APL 22-027) concerning compliance with the state’s network adequacy and timely access...more
Increasing mental health care needs for minors present a range of legal issues for children, parents, health care providers and health care payors. While state laws typically govern who has the power to consent to or refuse...more
3/30/2022
/ Consent ,
Department of Health and Human Services (HHS) ,
Health Insurance Portability and Accountability Act (HIPAA) ,
Healthcare Reform ,
Medical Records ,
Mental Health ,
Minor Children ,
OCR ,
Patient Access ,
Regulatory Agenda ,
Regulatory Standards ,
SAMHSA ,
Scope of Treatment ,
Substance Abuse
Despite the unprecedented challenges of the COVID-19 pandemic, mergers and acquisitions in the health care industry have continued apace and show no signs of slowing....more
Commercials, news articles and targeted social media advertisements abound offering virtual mental health services from providers like Talkspace and Calm. These startups are just a few of the many companies offering...more
9/30/2021
/ Coronavirus/COVID-19 ,
Health Care Providers ,
Health Insurance ,
Health Technology ,
Infectious Diseases ,
Mental Health ,
Online Platforms ,
Patient Access ,
Startups ,
Telehealth ,
Telemedicine ,
Therapeutic Services ,
Unicorns
On August 11, 2021, United Healthcare and its affiliates were served with separate enforcement lawsuits by the Department of Labor (DOL) and the New York Attorney General (NY AG) involving mental health parity, among other...more
9/14/2021
/ Department of Labor (DOL) ,
Employee Benefits ,
Employee Retirement Income Security Act (ERISA) ,
Enforcement Actions ,
Explanation of Benefits (EOBs) ,
Medical Reimbursement ,
Mental Health ,
Mental Health Parity Rule ,
MHPAEA ,
NQTLs ,
Out of Network Provider ,
Outlier Payments ,
Outpatient Services ,
Settlement Agreements
On July 22, 2021, a bipartisan group of senators led by Chuck Grassley (R-IA) introduced the False Claims Amendments Act of 2021 (S.B. 2428). As the name suggests, the bill proposes certain amendments to the False Claims Act,...more
As the race to vaccinate continues, state and federal enforcement agencies are hard at work investigating and prosecuting COVID-19-related health care fraud. As Acting Assistant Attorney General Nicholas L. McQuaid of the...more
On August 3, 2020, the California Supreme Court held in Ixchel Pharma, LLC v. Biogen, Inc. that tortious interference with at-will contracts requires establishing wrongful conduct independent of interference itself. 9 Cal....more
In recent Employee Retirement Income Security Act of 1974 (ERISA) litigation challenging benefit decisions by plan administrators and fiduciaries, litigants have been pleading closely related claims under multiple ERISA...more
3/3/2020
/ Abuse of Discretion ,
Arbitrary and Capricious ,
Benefit Plan Sponsors ,
Breach of Duty ,
De Novo Standard of Review ,
Denial of Benefits ,
Employee Retirement Income Security Act (ERISA) ,
Pension Funds ,
Pensions ,
Plan Administrators ,
Scope of Discovery Requests ,
Standard of Review
Editor’s Note: Litigators and in-house counsel for both payers and providers in the reimbursement arena should be aware of recently enacted legislation regulating “surprise” medical billing. In this article, we discuss some...more
Increased prescribing of opioid medications over the course of nearly two decades has led to widespread misuse of both prescription and nonprescription opioids. In 2018 alone, 10.3 million people misused prescription opioids,...more
On August 26, 2019, Cleveland County, Oklahoma, District Court Judge Thad Balkman issued a 42-page decision ordering Johnson & Johnson to pay more than $570 million for harm it allegedly caused the state of Oklahoma by...more
In July 2019, Judge Gilliam of the Northern District of California issued an order interpreting the different avenues a plaintiff may pursue in bringing a parity claim—a decision that may be consequential to health plans and...more
On June 24, 2019, President Donald Trump issued an “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” The stated purpose of the Order is to “enhance the ability of...more
Editor’s Note: The article below provides an update on the risk corridors program (Program) created by the Patient Protection and Affordable Care Act (ACA). The Program was intended to encourage qualified health plan (QHP)...more
Editor’s Note: Healthcare organizations are increasingly prime targets for class actions. Below we briefly summarize the recent changes to Federal Rule of Civil Procedure 23 and their impact on class actions. ...more
On October 1, 2018, the U.S. Supreme Court denied a petition for a writ of certiorari asking the Court to weigh in on just how precisely a whistleblower must plead the submission of a false claim. Since the False Claims Act...more
Recent Ninth Circuit case law created uncertainty about the requirements for establishing an implied false certification claim following the Supreme Court’s decision in Universal Health Services, Inc. v. United States ex rel....more
On June 6, 2018, the Ninth Circuit revived a lawsuit, Danny P. et al. v. Catholic Health Initiatives, No. 16-35609, challenging the denial of a claim for an inpatient stay at a residential mental health treatment facility by...more
On May 1, 2018, the U.S. Departments of Labor, Health & Human Services and the Treasury (Departments) clarified the Patient Protection and Affordable Care Act’s (ACA) “greatest-of-three” regulation (GOT regulation) in...more
On September 23, 2016, the California Legislature passed, and Governor Jerry Brown signed, Assembly Bill 72 (AB 72 or the Act), creating a new regime for the regulation of “surprise bills.” (Health...more
On April 9, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a Health & Human Services (HHS) Notice of Benefit and Payment Parameters for 2019 (final rule). The final rule is the first time the Trump...more
Connecting Justice-Involved Populations to Health Coverage and Care -
Editor’s Note: The importance of connecting justice-involved populations to health coverage and care is evident from the high levels of physical and...more