News & Analysis as of

Medical Necessity

Health Care Compliance Association (HCCA)

[Virtual Event] Clinical Practice Compliance Conference - October 15th - 16th, 8:00 am - 5:00 pm CT

Are you in a clinical setting and looking for updates on compliance trends and initiatives? Join us this October for HCCA’s Virtual Clinical Practice Compliance Conference and get insights, updates, and strategies for...more

Akerman LLP - Health Law Rx

What’s it to You? Justice Scalia’s 41-Year-Old Gatekeeping Question on “Standing” Influences Court to Uphold FDA’s Regulation of...

Mifepristone is safe for now. On June 13, 2024, the Supreme Court unanimously held that the plaintiffs — doctors and medical associations alike — lacked standing to challenge 2000 and 2019 FDA approvals of mifepristone (brand...more

Fenwick & West LLP

SCOTUS Unanimously Preserves Access to Abortion Pill

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On Thursday, June 13, the Supreme Court maintained access to the abortion pill, mifepristone. This medication, in conjunction with misoprostol, was used in nearly two-thirds of all U.S. abortion and miscarriage treatments...more

Manatt, Phelps & Phillips, LLP

Supreme Court Will Hear Medication Abortion Case; Three States Ask to Intervene in District Court

The Big Picture - On December 13, 2023, the Supreme Court announced its intention to review the August 16 ruling by the Fifth Circuit in Alliance for Hippocratic Medicine (AHM) v. U.S. Food and Drug Administration, et al....more

Hendershot Cowart P.C.

Physicians: Diagnose & Document Therapeutic Necessity for IV Hydration Treatments

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Retail medicine has directly challenged the role of physicians as gatekeepers to prescription medications and medical procedures, and as fiduciaries to their patients. Some providers in the current IV hydration market are...more

Manatt, Phelps & Phillips, LLP

Wit Redux—Again: Ninth Circuit Again Supersedes Its Prior Opinion in Landmark Mental Health Case

Editor’s Note: In the article below, Manatt discusses the Ninth Circuit’s new opinion in the ongoing Wit v. United Behavioral Health litigation and the changes from the now-vacated January 2023 Wit decision. ...more

Health Care Compliance Association (HCCA)

[Event] 2023 Healthcare Enforcement Compliance Conference - November 5th - 7th, Washington, DC

Hear directly from the enforcement community - Want to gain insight into properly monitoring, detecting, investigating, and managing violations? Join us at HCCA’s Annual Healthcare Enforcement Compliance Conference to...more

King & Spalding

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

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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

Health Care Compliance Association (HCCA)

Enforcement actions relating to a lack of medical necessity

In a climate of shrinking margins, diminishing reimbursement, and frequent denials, healthcare organizations may make efforts to increase the volume of services they provide, especially those that are more profitable. Of...more

Manatt, Phelps & Phillips, LLP

[Webinar] Navigating the Rapidly Changing Medicare Advantage Regulatory Landscape - April 11th, 1:00 pm - 2:00 pm ET

Medicare Advantage (MA) plans now cover about half of Medicare beneficiaries, and with that enrollment growth has come increased scrutiny from federal and state regulators. As federal regulators complete a busy season of...more

Manatt, Phelps & Phillips, LLP

Wit Redux: Ninth Circuit Issues New Superseding Opinion in Landmark Mental Health Case

The Ninth Circuit has issued a new opinion in the long-running Wit v. United Behavioral Health litigation that changes the legal landscape for ERISA class actions. The Ninth Circuit’s opinion includes significant holdings on...more

Health Care Compliance Association (HCCA)

[Event] Regional Healthcare Compliance Conference - January 27th, Lake Buena Vista, FL

Looking for compliance education and networking in your area? HCCA’s Regional Healthcare Compliance Conferences offer practitioners convenient, local compliance education, including updates on the latest news in regulatory...more

Nelson Mullins Riley & Scarborough LLP

Compliance and Regulatory Enforcement Update for Labs

Whether you operated a traditional diagnostic lab, a toxicology lab, or one that performs high-complexity genetic and genomic testing, there were plenty of regulatory nightmares to keep you up at night in 2022. It seems “the...more

Foley & Lardner LLP

California Moves to Transform the Behavioral Health Delivery System – are Payers and Providers Ready?

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This is the first article in a series addressing key changes to the California health care marketplace, focused on changes to California’s behavioral health delivery systems. Forthcoming articles in the series will address...more

Health Care Compliance Association (HCCA)

[Virtual Event] Healthcare Enforcement Compliance Conference - November 7th - 9th, 8:55 am - 3:30 pm CST

Hear directly from the enforcement community - Want to gain insight into properly monitoring, detecting, investigating, and managing violations? Join us virtually at HCCA’s Annual Healthcare Enforcement Compliance...more

Health Care Compliance Association (HCCA)

[Webinar] The Evolving Landscape of Medical Necessity in Healthcare Compliance - September 14th, 12:00 pm - 1:30 pm CDT

Learning Objectives - Identify how the medical necessity of services is defined and by whom; - Review the current trends in medical necessity enforcement - Evaluate how to incorporate the medical necessity of services...more

Health Care Compliance Association (HCCA)

Physician coding and billing risks

CT magazine (August 2022) - Medical school curriculum is heavy in anatomy, physiology, biochemistry, pathology, and clinical rotations or clerkships. There is very little, if any, instruction on proper coding and billing...more

Laughlin, Falbo, Levy & Moresi LLP

Utilization Review Denials v. Utilization Review Deferrals

Ever since utilization review (UR) became a mandatory requirement for all medical treatment requests, there have been numerous attempts to challenge not only individual UR determinations and the timeframes in which they have...more

Sheppard Mullin Richter & Hampton LLP

Less is More: Brevity is the Soul of Wit

Last month, a three-judge panel in the Ninth Circuit reversed the Northern District of California’s ruling in Wit v. United Behavioral Health. In Wit, the district court ruled that United Behavioral Health (“UBH”) breached...more

Bass, Berry & Sims PLC

Fifth Circuit Affirms Criminal Healthcare Fraud Convictions of Hospice and Home Health Executives

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On March 24, the U.S. Court of Appeals for the Fifth Circuit affirmed the criminal healthcare fraud convictions of two individuals who ran a network of home health and hospice centers in Texas. According to the Fifth Circuit,...more

Whitcomb Selinsky, PC

Court of Appeals Finds Medical Necessity Material in FCA Liability

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Jane Winter, former Director of Care Management at Gardens Regional Hospital filed a qui tam action under the False Claims Act (FCA).  Winter alleged Gardens Regional Hospital and Medical Center, Inc. submitted, or caused to...more

Oberheiden P.C.

5 Tips for Lab Compliance in 2023

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In many ways, the COVID-19 pandemic increased the business opportunities available to clinical labs, including molecular and respiratory labs. As the nation—and the world—struggled to develop adequate testing infrastructure,...more

Oberheiden P.C.

What You Need to Know About Continuous Glucose Monitoring Compliance

Oberheiden P.C. on

For diabetic patients and the doctors who treat them, blood sugar levels are crucially important. However, the traditional method of testing one’s blood sugar with a pin-prick is undesirable for many patients, which leads to...more

Oberheiden P.C.

Federal Authorities Place Cardiovascular Stress Testing Under the Microscope

Oberheiden P.C. on

Cardiovascular stress testing to diagnose patients with coronary artery disease (CAD) and other related types of conditions can be a highly-effective tool in many cases. In fact, many cardiologists routinely recommend stress...more

Robinson+Cole Health Law Diagnosis

New Connecticut Law Expands Authority of DDS to Consent to Emergency Medical Care on Behalf of Certain Patients in Residential...

On July 7, 2021 Connecticut Governor Ned Lamont signed into law Public Act 21-135 (the “Act”). The Act, among other things, makes a revision to the Department of Developmental Services (DDS) statutes allowing DDS regional or...more

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