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
The hazy analytical framework for “bundling” cases has come into sharper focus, potentially making it harder for plaintiffs to prevail in certain antitrust cases. ...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
On June 25, the U.S. Supreme Court ruled that American Express’s contractual “antisteering provisions” did not violate section 1 of the Sherman Act....more
6/28/2018
/ American Express ,
Anti-Steering Rules ,
Anticompetitive Agreements ,
Antitrust Provisions ,
Burden of Proof ,
Credit Card Surcharges ,
Merchant Fees ,
Merchants ,
Ohio v American Express ,
Rule-of-Reason Analysis ,
SCOTUS
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
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
Often lost in the cacophony of headlines surrounding rising health care costs is the promise that value-based contracting offers as a possible solution. In contrast to the traditional fee-for-service model, value-based...more
10/6/2017
/ Alternative Payment Models (APM) ,
Anti-Kickback Statute ,
Big Data ,
Centers for Medicare & Medicaid Services (CMS) ,
False Claims Act (FCA) ,
Food and Drug Administration (FDA) ,
Medicaid ,
Medical Devices ,
Off-Label Promotion ,
OIG ,
Pharmaceutical Industry ,
Prescription Drugs ,
Regulatory Standards ,
Value-Based Payments
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 March 22, the U.S. House of Representatives passed the Competitive Health Insurance Reform Act of 2017, which would repeal the current limited federal antitrust immunity for health insurers. The bill would amend the...more
On March 27, the United States Supreme Court, in a 5-4 opinion, further heightened plaintiffs’ burden in seeking class certification. The Court held that, under Rule 23, plaintiffs must “‘tie each theory of antitrust impact’...more
The Federal Trade Commission (FTC) recently issued its first advisory opinion addressing clinical integration programs since the enactment of the Affordable Care Act (ACA). Without a doubt the advisory opinion is useful for...more
After three years at the helm of the Federal Trade Commission (FTC), Chairman Jon Leibowitz stepped down. Without a doubt Chairman Leibowitz has been a visible and relentless advocate for restricting pay-for-day or reverse...more