In May, California’s attorney general (AG) charged a local dermatologist with more than 20 counts of fraud after uncovering a scheme that allegedly resulted in the state’s Medicaid program paying out over $1.3 million for...more
CalAIM is an initiative of the California Department of Health Care Services (the Department) to improve the quality of life and health outcomes of Medi-Cal members by implementing delivery system, program, and payment...more
Recent federally qualified health center (FQHC) litigation highlights the impact state Medicaid agencies have on FQHC reimbursement. The important decisions summarized below all involve FQHC disputes over state Medicaid...more
In our practices, we are seeing an increasing number of denials or de facto denials of Medi-Cal provider enrollments. The consequences of a Medi-Cal enrollment denial can be quite serious. First, a provider may not receive...more
California AG Rob Bonta settled with pharmacy benefit manager (PBM) Centene Corporation and its subsidiaries in connection with alleged overcharges by Centene to California’s Medi-Cal program....more
Here are curated AG and federal regulatory news stories highlighting key areas in which state and federal regulators’ decisions are having an impact across the US: •AG James Settles over Sale of Unlawful Monitoring Software-...more
California AG Rob Bonta settled with Hey Favor, Inc. and affiliated and predecessor entities that previously conducted business as “The Pill Club” for allegedly violating the California False Claims Act by knowingly...more
In this episode, Foley partner Anil Shankar discusses California’s new Medicaid wavier called CalAIM, (California Advancing and Innovating Medi-Cal, the multiyear care delivery and payment reform initiative led by the...more
The following is a summary of the federal Health and Human Services agency’s Office of Inspector General (OIG) reports of fraud and abuse enforcement activity across the country. The enforcement actions reported are based...more
On December 29, 2021, the California Department of Health Care Services (DHCS) announced CMS’s approval of its California Advancing and Innovating Medi-Cal (CalAIM) proposal. CalAIM’s launch on January 1, 2022 is part of a...more
On April 1, 2021, the California Department of Health Care Services (“DHCS”) will be transitioning all Medi-Cal pharmacy benefits from managed care to fee-for-service (“FFS”). This new system to administer FFS pharmacy...more
California Governor Gavin Newsom recently signed into law two bills that expand the delivery of telehealth services in the state. In particular, the legislation: • Permits providers to prescribe medications without a...more
The California Department of Health Care Services (“DHCS”) recently revised its Medi-Cal telehealth policy to allow providers increased flexibility in their use of telehealth as a modality for delivering medically necessary...more
In recent weeks, the states of California and Washington, and New York City have proposed expanding Medicaid eligibility for undocumented young adults. Given Medicaid’s combination of state and federal funding, House and...more
To date, 34 states (including D.C.) have adopted Medicaid expansion. Of the remaining 17 states, some are considering expanding Medicaid. States with recent activity relating to Medicaid expansion include Florida, Idaho,...more
As described in an April 17, 2018 article originally posted on the Sheppard Mullin Richter and Hampton, LLP False Claims Act Defense Blog, Kmart Corporation and the U.S. Department of Justice entered into a False Claims Act...more
California’s First District Court of Appeal (“Court of Appeal”) has recognized that percentage-based billing arrangements do not violate California’s Medi-Cal laws and that the California Department of Health Care Services...more
The Bankruptcy Court for the Central District of California examined the scope of the doctrine of recoupment for Medicaid and related payments, allowing the deduction by the state. The court held that the California...more
On December 30, 2015, CMS approved California’s request for a five-year waiver to extend California’s Section 1115(a) demonstration project, entitled “California Medi-Cal 2020 Demonstration.” According to the CMS approval...more
The Centers for Medicare and Medicaid Services (CMS) has approved a new section 1115 Medicaid demonstration for the state of California. Under the demonstration, the California Department of Health Care Services (DHCS) will...more
In a decision handed down on August 7, 2015, the United States Court of Appeals for the District of Columbia Circuit upheld the denial of the providers' bad debt claims associated with dual eligible beneficiaries. Grossmont...more
On March 31, 2015, a 5-4 plurality of the Supreme Court of the United States ruled that Medicaid providers do not have a private right of action under the Medicaid statute to challenge reimbursement rates. The Supreme Court’s...more