A task force led by Democratic lawmakers in Delaware has recommended that the state adopt its own individual mandate to bolster the financial stability of its Affordable Care Act (ACA) exchange marketplace....more
On October 26, the Centers for Medicare and Medicaid Services (CMS) issued a notice of proposed rulemaking that would significantly alter the risk adjustment data validation (RADV) methodology that applies to Medicare...more
As litigation surrounding the Affordable Care Act and its mandates abounds, the Iowa Farm Bureau announced three new health plans that will deny coverage to individuals with preexisting conditions (a denial prohibited under...more
In a departure from the otherwise stark division across party lines when it comes to health care, a new bipartisan effort has emerged to protect consumers from “surprise medical bills” for out-of-network charges. ...more
The U.S. District Court for the District of Columbia handed down a major victory to Medicare Advantage issuers on September 7, 2018, vacating a 2014 CMS regulation relating to Medicare Advantage overpayments. ...more
9/12/2018
/ Centers for Medicare & Medicaid Services (CMS) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Fraud ,
Life Sciences ,
Medicare ,
Medicare Advantage ,
Overpayment ,
Overpayment Recovery Time Limits ,
Regulatory Oversight ,
Regulatory Requirements ,
Reporting Requirements
A new Sixth Circuit decision may signal an emerging trend on whether insurers must cover claims made by policyholders who fall victim to phishing scams....more
7/31/2018
/ Commercial Insurance Policies ,
Cyber Crimes ,
Cyber Insurance ,
Data Security ,
Denial of Insurance Coverage ,
Fraudulent Wire Transfers ,
Hackers ,
Insurance Claims ,
Insurance Industry ,
Insurance Litigation ,
Phishing Scams ,
Policy Terms ,
Popular ,
Travelers Property Casualty Co.
New Jersey legislators are working to enact a law that will provide policyholders with potentially punishing recourse if their insurance carriers mishandle their claims for benefits....more
We have recently seen an uptick in state initiatives designed to skirt requirements under the Affordable Care Act (ACA). We last wrote about Idaho’s failed attempt to permit health insurers to sell noncompliant plans, which...more
In a highly anticipated decision, the Pennsylvania Superior Court vacated an eyebrow-raising $21 million award for an auto policyholder and found that the insurer did not act in bad faith....more
We recently wrote about Idaho’s failed attempt to permit health insurers to sell policies that did not comply with Affordable Care Act (ACA) requirements for the individual insurance market. ...more
Last month, we reported that Idaho announced a controversial plan to allow insurers to sell policies that do not comply with certain ACA requirements — a move that some feared would set a precedent for other states. ...more
In the wake of recent failures to repeal the Affordable Care Act, one state has decided to take matters into its own hands. Idaho recently announced a controversial plan to allow insurers to sell policies that do not comply...more
On October 5, a federal district court in California dealt a significant setback to the government’s efforts to extend False Claims Act (FCA) liability to Medicare risk adjustment submissions....more
10/16/2017
/ Centers for Medicare & Medicaid Services (CMS) ,
Dismissals ,
False Claims Act (FCA) ,
FRCP 9(b) ,
Health Insurance ,
Healthcare Fraud ,
Materiality ,
Medicare ,
Medicare Advantage ,
Risk Adjustment Formula ,
Scienter ,
UnitedHealth ,
Whistleblowers
It has been one year since the U.S. Supreme Court’s landmark ruling in Universal Health Services v. United States ex rel. Escobar, which resolved a circuit split as to the validity of the implied false certification theory...more
9/21/2017
/ Conditions of Payment ,
False Claims Act (FCA) ,
False Implied Certification Theory ,
Federal Contractors ,
Health Care Providers ,
Healthcare Fraud ,
Implied Certification ,
Materiality ,
Medicaid ,
Motion to Dismiss ,
SCOTUS ,
Universal Health Services Inc v United States ex rel Escobar ,
Unlicensed Medical Providers
A federal appeals court recently brushed aside the claims of several health care providers, in large part because of the language in the assignment forms signed by their patients. The opinion from the U.S. Court of Appeals...more
On December 15, 2014, the Pennsylvania Supreme Court broke its long silence on the gist of the action doctrine when it issued its decision in Bruno v. Erie Insurance Co. The gist of the action doctrine precludes a plaintiff...more
On August 26, the United States Court of Appeals for the Third Circuit affirmed the District Court’s dismissal of the Fair Labor Standards Act (FLSA) overtime claims brought against a myriad of health care systems and their...more