Under the No Surprises Act, “open negotiation” is the period of time during which payers must disclose to providers important information regarding the claim at issue. On June 14, 2024, CMS announced a 120-calendar-day...more
A multistate coalition of 17 Democratic and 5 Republican AGs wrote a letter to UnitedHealth Group Inc. urging the company to improve its response following a cyberattack on its subsidiary Change Healthcare, which provides a...more
On April 11, 2024, the U.S. Court of Appeals for the Ninth Circuit, in Ryan S. v. UnitedHealth Group, Inc., set a very broad pleading standard to allege a violation of the Paul Wellstone and Pete Domenici Mental Health Parity...more
Illumina Agrees to Unwind Acquisition of Grail Following Fifth Circuit Decision. On December 15, 2023, the Fifth Circuit vacated the FTC’s order that Illumina unwind its acquisition of Grail—a developer of a multi-cancer...more
With the surge of interest in artificial intelligence (AI), it should be no surprise that health insurers have come under scrutiny concerning their use of AI predictive tools to deny medical insurance claims. The question...more
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
vOn July 19, 2023, the U.S. antitrust enforcers, the Federal Trade Commission (“FTC”) and the Antitrust Division of the Department of Justice (“DOJ”) (collectively, the “Agencies”), released draft merger guidelines for public...more
Prior authorizations, one of health insurers’ many “utilization management” techniques, is a hot topic amongst practicing physicians, patients, and regulators, to name a few. The prior-authorization process requires a health...more
In a recent decision, the US District Court for the District of Utah granted United Healthcare’s (UHC) motion for summary judgment on the plaintiff’s facial and as-applied claims under the Mental Health Parity Act. If...more
An appeal brought before the Texas Supreme Court could unleash a wave of legal action by out-of-network ER physicians pursuing insurers for underpayment of claims. Unlike in-network providers who negotiate reimbursement...more
Thursday, January 13 was the last day of the virtual J.P. Morgan Annual Healthcare Conference for 2022. And since the conference was virtual, what better topic to start us off today than a consideration of the new...more
A jury last week awarded TeamHealth $60 million in punitive damages and late last month awarded TeamHealth $2.65 million in compensatory damages against UnitedHealthcare for underpaying TeamHealth affiliates for...more
We previously blogged about the new Mental Health Parity and Addiction Equity Act (MHPAEA) reporting and disclosure requirements established by the Consolidated Appropriation Act, 2021 (CAA). As a refresher, employers...more
The D.C. Circuit Court overturned UnitedHealthcare’s victory in the lower court that resulted in vacatur of the Medicare Advantage 60-day overpayment rule (the Overpayment Rule). Last week, the D.C. Circuit Court held that...more
On August 13, 2021, the D.C. Circuit Court of Appeals reversed a district court opinion vacating CMS’ Overpayment Rule, 42 C.F.R. 422.326, for Medicare Advantage organizations (“MAOs”). UnitedHealthcare Insurance Co. et al....more
The Federal Trade Commission has issued orders to five health insurers and two health systems requiring them to provide information that will assist the FTC in studying the competitive effects of certificates of public...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
Payers are increasingly establishing purported “site of service” policies and guidelines that restrict the circumstances under which members may obtain certain services at hospital outpatient departments (HOPDs). In the...more
With the end of week 12 came the end of the second funnel and the last chance for many policy bills to continue being considered this session. A good reference for whether a bill is still eligible for consideration is to...more
The False Claims Act is the government’s weapon of choice in fighting healthcare fraud. In the beginning of the Obama Administration, Congress amended the False Claims Act and enacted a wish list from DOJ prosecutors. ...more
The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit, United States of America ex rel Benjamin Poehling v. Unitedhealth Group Inc., No. 16-08697 (Cent. Dist. Cal. Sep. 17, 2010), ECF No. 79, against...more
A federal district court recently ruled that an employer-initiated program known as Onionhead was a religion for the purposes of Title VII of the Civil Rights Act of 1964. In Equal Employment Opportunity Commission v. United...more
In 2011, the California legislature passed Insurance Code Section 10110.6 which bans the use of discretionary clauses in any policy, contract, certificate, or agreement offered, issued, delivered, or renewed, whether or not...more
Today’s riddle: A physician sues defendants for defamation. The defendants move to compel the arbitration clause of a contract the physician used to have with a nonparty. The defendants win the argument. What’s the...more
Since the Affordable Care Act (the “ACA”) was enacted in 2010, the health care industry has been on the edge of its proverbial seat waiting to see which care delivery models are best suited to sustain all the changes: to...more