Hooper, Kearney and Macklin on Cutting Edge Topics in the False Claims Act
Polsinelli Podcast - Health Care Payment Changes: From Service to Value
In the wake of the December 4, 2024 fatal shooting of UnitedHealthcare’s CEO Brian Thompson, questions were raised about insurance claim denial practices. Several news outlets noted that UnitedHealth Group’s profits have been...more
On December 11, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a Special Fraud Alert (SFA) on what it refers to as “suspect” marketing schemes involving “questionable payments and...more
On the heels of recent scrutiny of health care professional (“HCP”) arrangements with brokers and agents and Medicare Advantage Organization (“MAO”) arrangements with providers, including through the U.S. Department of...more
A recent OIG report found that diagnoses reported in 2022 Medicare Advantage (MA) encounter data based only on health risk assessments (HRA) and HRA-linked chart reviews resulted in CMS making additional risk-adjusted...more
The Centers for Medicare & Medicaid Services (CMS) have released the proposed updates to the Medicare payment policies and rates for skilled nursing facilities (SNFs) for 2024. While the ruling is not final, “CMS estimates...more
On March 31, 2023, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced the finalized capitation rates and payment policies for the 2024 Medicare...more
AGG Healthcare attorneys Lanchi Bombalier and Charmaine Mech recently attended the American Health Law Association (AHLA)’s Institute on Medicare and Medicaid Payment Issues in Baltimore, Maryland, from March 23-25, 2022. The...more
On July 13th, group health plans and health insurance issuers subject to the Federal No Surprises Act (the “Act”) received the first phase of interim final rules promulgated under the Act (the “Rules”) and issued by the...more
Last week, the Court of Appeal gave a victory to non-contracted providers of emergency medical services. In San Jose Neurospine v. Aetna Health of California, the court rejected Aetna's position that because the provider "did...more
On August 13, 2019 the D.C. Circuit Court of Appeals (the D.C. Circuit) issued an opinion in Children’s Hospital Association of Texas v. Azar (No. 18-5135), allowing the Department of Health and Human Services (HHS) to...more
On July 11, 2019, the Centers for Medicare and Medicaid Services (“CMS”) announced a proposed rule for home health agency Medicare reimbursement that would increase payments by an aggregate 1.3% for 2020, amounting to $250...more
Health Plans’ Use of Policies and Guidelines to Reduce Coverage and Reimbursement - A technique we have seen payers use more commonly in recent months than in the past is to unilaterally implement policies or “clinical...more
The United States Senate is currently considering bipartisan legislation that would establish statutory limits on the financial exposure of certain patients to so-called “surprise” medical bills....more
The Final Rule. In a Final Rule posted by CMS last Tuesday, July 24, 2018, CMS announced that $10.4 billion in “risk adjustment transfers” (“Risk Transfers”) for benefit year 2017 (as calculated pursuant to the Affordable...more
On Tuesday, July 24, the Centers for Medicare and Medicaid Services (CMS) issued a final rule intended to clarify the program methodology and reinstate payments under the Affordable Care Act's (ACA) permanent risk adjustment...more
As 2017 drew to a close, some health plans and healthcare providers across the country were still busy trying to finalize contracts for in-network services for 2018 and beyond. A number of negotiations made the headlines in...more
Providers have just a couple more days to challenge Medicare’s proposed 2018 value modifier payment adjustments. On September 18, 2017, Medicare released quality reports and measures used to calculate quality-based payment...more
Of the many business, operational, legal, regulatory and clinical obstacles standing in the way of widespread delivery of personalized medicine, the single greatest challenge may lie in solving the reimbursement puzzle....more
Health Plans and health care providers are getting into each other’s business. This payor/provider convergence has taken different forms. Health systems have ventured into the health insurance business by acquiring or...more
Since I began writing this year-end review in 2013, there have been some common themes – a shift to pay for quality and away from fee-for service, much of which has been brought about by the Affordable Care Act (ACA): efforts...more
CMS, in a collaboration with American’s Health Insurance Plans (AHIP), announced on February 16, 2016, seven sets of “core measures” to align quality measures required for physician reporting. These core measures align the...more
Many healthcare facilities and physicians waive the insurance copayment for physicians and their families (known as professional courtesy) or other patients. Yet, despite how prevalent the practice is and the limited...more
Beginning Monday, July 14, 2014, the review, dispute and correction process outlined the National Physician Payment Transparency Program (also known as the "Sunshine Act") opens on CMS's Open Payments website. Physicians and...more