The State of Healthcare Enforcement
Hospice Insights Podcast - Election Inspection: Be Proactive to Avoid Costly Election Statement Denials
Medicaid Cuts: Potential Challenges and Legal Implications for Long-Term Care Facilities — Assisted Living and the Law Podcast
False Claims Act Insights - How Payment Suspensions Can Impact FCA Litigation
Federal Court Strikes Down FDA Rule on LDTs - Thought Leaders in Health Law®
UPIC Audits
AGG Talks: Home Health & Hospice Podcast - Episode 8: Hospice Special Focus Program: Pumping the Brakes
Hospice Insights Podcast - Upping the Ante: Will CMS’s Enhanced Oversight Efforts Cause Hospices to Fold?
Podcast — Drug Pricing: What’s in the New CMS Medicaid Final Rule?
Hospice Insights Podcast - What a Difference No Deference Makes: Courts No Longer Bow to Administrative Agencies
Preparing for CMS Staffing Mandates — Assisted Living and the Law Podcast
Hospice Insights Podcast - Meet the New Laws, Same as the Old Laws: Overpayment Recoupment Update
Podcast — Drug Pricing: Takeaways From the Chicago Medicaid Drug Rebate Program Summit
Podcast — Drug Pricing: How the Demise of Chevron Deference and Other Litigation May Impact the Pharmaceutical Industry
The CMS Interoperability and Prior Authorization Rules
Podcast — Drug Pricing: How Are Payers Responding to the IRA?
Findings from Gibbins’ Annual Healthcare Bankruptcy Report
A Fond Farewell: Musings on the End of the Medicare Advantage Hospice Carve-In Demonstration
Video: Braidwood v. Becerra – Challenging the Affordable Care Act’s Preventive Services Coverage Provision – Thought Leaders in Health Law
Shortly following its announcement of sweeping changes to RADV audits, CMS shared industry guidance last week regarding upcoming deadlines for the submission of risk adjustment data corrections in advance of RADV sampling....more
SB 1120 (the “Bill”), which takes effect on January 1, 2025, amends existing California law to adopt guardrails around the use of artificial intelligence tools for the purpose of utilization management. As discussed in a...more
On September 28, California Gov. Gavin Newsom signed Senate Bill 1120 Health Care Coverage: Utilization Review into law, amending § 1367.01 of the Health and Safety Code and § 10123.135 of the state’s Insurance Code....more
On September 13, the U.S. Department of Health and Human Services Office of Inspector General (OIG) published Advisory Opinion 24-08, in which it declined to approve a proposal by a Medicare Advantage organization (MAO)...more
On April 4, 2024, the Centers for Medicare & Medicaid Services (“CMS”) published its Final Rule amending the existing Medicare Advantage (“MA”) agent broker compensation regulations. The Final Rule has significant...more
On April 1, 2024, the US Centers for Medicare & Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and Part C and D Payment Policies (Rate Announcement). CMS...more
Hosted by American Conference Institute, the 2nd Annual Legal, Regulatory and Compliance Summit on Medicare Advantage returns for another exciting year with curated programming that will address the latest oversight and...more
CMS published the Calendar Year (“CY”) 2024 Medicare Advantage (“MA”) Capitation Rates and Part C and Part D Payment Policies (“Rate Announcement“) on March 31 and, five days later, issued the MA and Part D final rule for...more
More than four years after it was proposed, on February 1, 2023 the Centers for Medicare & Medicaid Services (CMS) published the long-awaited risk adjustment data validation (RADV) Final Rule (Final Rule) that will affect...more
The Centers for Medicare & Medicaid Services (CMS) was very busy last week! On Jan. 30, CMS issued its long-awaited Risk Adjustment Data Validation (RADV) Final Rule....more
On January 30, 2023, CMS posted for inspection a final rule describing its Risk Adjustment Data Validation audit methodology (the Final RADV Rule). As we have discussed in prior alerts, the finalization of the RADV Rule,...more
On Tuesday, December 13, the Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule (“New Proposed Rule”) to improve the prior authorization process and advance interoperability for Medicare Advantage...more
Over the past year, the federal government has taken concrete steps to fulfill its promise of a heightened commitment to investigating and enforcing health care fraud within the Medicare Advantage program (Medicare Part C). ...more
The Department of Justice (DOJ) recently filed suit against Anthem, Inc. (Anthem) alleging that the Medicare Advantage Organization (MAO) violated the False Claims Act (FCA) when it knowingly failed to delete inaccurate...more
In this episode, Gary Qualls discusses a recent development in payer litigation, regarding a provider’s recovery of Medicare Advantage payments pursuant to a Medicare Advantage contract. Specifically, a recent federal case...more
On March 31, 2017, Judge Rosemary Collyer of the United States District Court for the District of Columbia held that plaintiffs UnitedHealthcare Insurance Company et al. (“United”) had standing to challenge CMS’s overpayment...more
The District of Columbia federal court recently ruled that a proposed $37 billion merger between health insurance giants Aetna and Humana cannot proceed, granting the US Department of Justice’s bid to block the combination on...more
On November 2, 2016, the Centers for Medicare and Medicaid Services (CMS), released the 2017 Medicare Physician Fee Schedule (MPFS) final rule, which finalized a number of new policies designed to improve Medicare payment for...more
Humana Medical Plan, Inc. v. Western Heritage Insurance Co., case number 15-11436. Liability insurers beware, as the 11th Circuit held that Medicare Advantage Organizations (MAO) are entitled to the same rights...more