News & Analysis as of

Hospitals Medicare Advantage Health Insurance

Davis Wright Tremaine LLP

Anthem's New Chargemaster-Based Claim Edits: Which Charges and Providers Will Anthem's New Process Target and How Will It Impact...

Effective August 1, 2025, Anthem will implement a new claims-editing process that adjusts payments for Medicare Advantage (MA) claims based on an undisclosed, customized chargemaster table. The announcement identifies claims...more

Patrick Malone & Associates P.C. | DC Injury...

Better Health Care Newsletter - March 2025

The giant firms  that track trends for big businesses have glum news for all of us: Health care costs are spiking anew this year. The rise, one consultancy predicts, will be the highest in 13 years....more

Sheppard Mullin Richter & Hampton LLP

Healthcare Industry Leaders Predict Four Areas to Watch After the U.S. Election: Takeaways from the Business of Health Care...

The recent U.S. election has had profound implications for the healthcare industry, prompting industry leaders to reexamine their strategies and day-to-day operations. At the Miami Herbert Business School’s annual “The...more

Holland & Knight LLP

Regulation of AI in Healthcare Utilization Management and Prior Authorization Increases

Holland & Knight LLP on

Over the past two years, federal and state government agencies have moved to regulate the deployment of artificial intelligence (AI) in the healthcare setting, including in the utilization management (UM) and prior...more

McDermott+

Regs, Regs and More Regs: The Biden Administration Releases Spring 2024 Unified Agenda

McDermott+ on

We are in the midst of a storm of regulations that are being released by the Centers for Medicare & Medicaid Services (CMS) and the US Department of Health and Human Services (HHS), including the Calendar Year (CY) 2025...more

Patrick Malone & Associates P.C. | DC Injury...

Better Health Care Newsletter - March 2024

Is Medicare Advantage really a Disadvantage for seniors and taxpayers? Our nation is graying rapidly. Every day, 10,000 baby boomers, members of one of the largest generations in U.S. history, hit the traditional...more

Stevens & Lee

CMS Final Rule: Medicare Advantage Plans Subject to Two-Midnight Coverage Condition

Stevens & Lee on

On June 5, 2023, CMS’s Final Rule regarding, among other things, “Technical Changes to the Medicare Advantage Program” will become effective – refer to the CMS Fact Sheet and the Final Rule as published in the Federal...more

Health Care Compliance Association (HCCA)

MA Final Rule: CMS Requires Two-Midnight Rule, Puts Limits on Internal Coverage Criteria

In what passes for neon lights in the regulatory world, CMS said Medicare Advantage (MA) plans must follow the two-midnight rule, its case-by-case exception and the inpatient-only (IPO) list, according to the final 2024 rule...more

Rivkin Radler LLP

CMS Issues Coronavirus Guidance

Rivkin Radler LLP on

Over the past week, the Centers for Medicare & Medicaid Services (CMS) has issued a flurry of guidance documents and FAQs regarding COVID-19 for healthcare providers in private practice, hospitals, nursing homes, hospices and...more

Sheppard Mullin Richter & Hampton LLP

Day 3 Notes at the 2020 J.P. Morgan Healthcare Conference

CMI, CMMI, and Changing the Consumer Experience in the U.S. and China - Case Mix Index: Sitting in multiple hospital, payor and physician organization presentations at the J.P. Morgan healthcare conference this year, it is...more

Epstein Becker & Green

7 Hot Health Care Industry Sectors for Investment, Growth & Consolidation in 2020

Based on their extensive experience advising health care industry clients, Epstein Becker Green attorneys and strategic advisors from EBG Advisors are predicting the “hot” health care sectors for investment, growth, and...more

King & Spalding

Health Plan Responsibility to Pay for Hospital Inpatient Care When Members Await Placement at Post-Acute Facilities

King & Spalding on

Hospitals that attempt to discharge a patient to a post-acute level of care but are not able to because they cannot find an appropriate accepting facility must continue providing care if the patient cannot be safely...more

K&L Gates LLP

K&L Gates Triage: Recent Developments in Provider v. Payer Litigation -- Medicare Advantage Disputes

K&L Gates LLP on

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

King & Spalding

Court Rules Hospitals Must Exhaust HHS Administrative Appeals Process for Medicare Advantage Out-of-Network Payment Dispute

King & Spalding on

According to a Georgia federal district court ruling issued on February 11, 2016, a group of hospitals must exhaust their out-of-network Medicare Advantage (MA) payment dispute through the Department of Health and Human...more

Foley & Lardner LLP

Clinical Laboratories: Proposed Rule Implements Requirements for Reporting and Payment Based on Private Payer Rates

Foley & Lardner LLP on

As required by a 2014 statute, CMS has issued proposed regulations (Proposed Rule) implementing new requirements for laboratory reporting of, and eventually basing Medicare payment on, rates for clinical laboratory services...more

McGuireWoods LLP

Washington Healthcare Update

McGuireWoods LLP on

This Week: CMS Releases Guidance on Fast Track Process for 1115 Waivers for Medicaid and CHIP... Healthcare.gov CEO Sends Letter to State Insurance Commissioners Concerning 2016 Premium Decisions... Medicare Board of Trustees...more

Foley & Lardner LLP

Insurer Wrongfully Passed Sequestration Cuts Through to Providers

Foley & Lardner LLP on

A Pennsylvania judge found, on May 6, 2015, that a Medicare Advantage Plan had no right under its participation agreements to pass CMS sequestration reductions through to participating providers. Judge R. Stanton Wettick Jr....more

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