by Porter Leslie , Chief Strategy Officer, Ametros Financial In the course of settling a worker’s compensation or liability case there are many obstacles to overcome. One of the most frequent challenges is reaching a settlement for the injured party’s future medical costs. While settling may be a scary thought for the injured party, the truth is that keeping the case open can also prove to be a huge hassle...

by Frederick Robinson , Thomas Dowdell , Carol Poindexter , Mark Faccenda , Selina Coleman and Blake Walsh* On February 11, 2016, DHHS’s Centers for Medicare & Medicaid Services (CMS), issued a final rule clarifying the requirement of § 1128J(d) of the Social Security Act (created by § 6402(d) of the Affordable Care Act) that health care providers must report and return overpayments within 60 days...

By Stacy L. Cook The New York attorney general recently entered into a settlement agreement with the University of Rochester Medical Center (URMC) for HIPAA violations. The enforcement action by New York comes on the heels of a HIPAA enforcement action by the Connecticut attorney general in early November 2015. Prior to the Health Information Technology for Economic and Clinical Health (HITECH) Act, only the federal...

A 2015 decision by the West Virginia Supreme Court of Appeals highlights the importance of following procedural formalities by making it clear that a failure to apply and maintain clear distinctions in what health care providers intend to classify as “peer review,” both before and during the actual activity, may compromise the privilege. In State ex rel Manor Care v. Stucky , the state’s highest court...

By Frank E. Sheeder The US Department of Justice has made it a priority to hold individuals accountable for organizational misdeeds – both civil and criminal. Through the recent Yates Memo, the DOJ is sending a message of deterrence to corporate leaders and their governing bodies. The Memo details a concerted DOJ initiative to hold individuals responsible for corporate misconduct. With this new initiative, the outcome...

By John W. Greenleaf III In today’s shifting health care landscape, providers are consolidating and forming strategic partnerships that position them to offer comprehensive, high-quality services at reasonable costs. Motivations vary, but in any merger, all parties want the same outcome – a seamlessly operating new entity. If they’re to succeed, merging corporate cultures must mesh in a happy marriage...

The U.S. Environmental Protection Agency (EPA) has announced two new proposed hazardous waste rules that EPA believes would clarify and simplify requirements for health care facilities and retail pharmacies to manage their unused pharmaceuticals that meet hazardous waste criteria, and would offer flexibility for occasional and small quantity hazardous waste generators in managing their waste. The first proposed rule...

By Lesli C. Esposito and Steven Levitsky The Federal Trade Commission is on a roll in its attack on what it considers anti-competitive effects in the healthcare industry. And that roll has consistently involved challenging activity that once appeared to be protected by state laws. Now, the FTC has taken on state CON (Certificate of Need) laws, arguing that they restrict price and non-price competition and may stifle...

By Serj Mooradian On July 20, Illinois Governor Bruce Rauner signed HB 3680 , the Interstate Medical Licensure Compact Act, making Illinois the eleventh state to sign on to the Interstate Medical Licensure Compact (the Compact). Illinois follows Alabama, Idaho, Iowa, Minnesota, Montana, Nevada, South Dakota, Utah, West Virginia and Wyoming. The Compact will provide a streamlined approach to multi-state licensure...

By Serj Mooradian On July 17, 2015, the United States Court of Appeals for the 2nd Circuit affirmed a district court decision that the Connecticut State Dental Commission did not violate the Equal Protection and Due Process Clauses of the federal Constitution when it promulgated a regulation that only licensed dentists may use a light emitting diode (LED) procedure for teeth whitening. The plaintiff in Sensational...

By Matthew L. Curtis and Michelle L. Warden Electronic Health Records (EHR) were generally promised to decrease costs and improve health-care outcomes. Setting aside whether those promises were well founded, EHR have posed new challenges for litigators. What makes sense in a clinical setting may not in a courtroom. What may be critically important in a medical malpractice action might be of no consequence or importance...

By: Kelsey S. Farbotko If you are one of the many health care providers wanting to appeal a Medicare contractor’s reimbursement decision, you may need to be prepared for a long wait. Over the last few years, the backlog of appeals to the administrative hearing level has grown into an untenable situation: according to the chief administrative law judge at the Department of Health and Human Services’ Office...

By Mark S. Thomas The U. S. Court of Appeals for the Second Circuit has affirmed a dismissal of claims by two physicians and their medical practice asserting standing under ERISA to enjoin an insurer from removing them from its coverage network. Rojas v. Cigna Health and Life Insurance Company , Case No. 14-3455 (2d Circ. July 15, 2015), held that, although the medical providers had a right to be reimbursed for services...

Rep. Mike Thompson (D-CA) and co-sponsors Rep. Gregg Harper (R-MS), Rep. Diane Black (R-TN), and Rep. Peter Welch (D-VT) announced, on July 7, 2015, the introduction of the Medicare Telehealth Parity Act of 2015 , forward-looking, bi-partisan legislation intended to modernize the way Medicare pays for telehealth services. Containing three implementation phases over a four year horizon, the Act proposes changes to Medicare...

By Stacy L. Cook On July 10, 2015, the Office for Civil Rights (OCR) announced a HIPAA settlement with St. Elizabeth’s Medical Center (SEMC), a tertiary care hospital in Brighton, Massachusetts. SEMC has agreed to pay $218,400 and adopt a robust corrective action plan. The settlement is the result of two alleged violations. First, SEMC workforce members filed a complaint of a HIPAA violation with the OCR in...

By Julie Veldman On June 25, 2015, the United States Department of Justice (DOJ) and the Michigan Attorney General (Michigan AG) sued four Michigan hospital systems for entering into agreements with a competitor to unlawfully allocate territories for the marketing of competing healthcare services and to limit competition between them. The Michigan hospital systems include Hillsdale Community Health Center (Hillsdale...

The federal Stark law prohibits physician referrals of “designated health services” payable by Medicare to entities with which the physician or an immediate family member has a financial relationship, unless the arrangement meets an exception. Enforcement initiatives aim at extending the reach of Stark to Medicaid as well. Various types of arrangements create financial relationships and, subject to certain...

By David Gruber, MD, MBA* Healthcare spending is forecast to increase from US$3 trillion in 2014 to US$5.2 trillion in 2023, reflecting a compound annual growth rate of 5.9 percent. US healthcare expenditures on a per capita basis are 1.9-2.6 times the amount spent by other developed nations despite having a much younger population. An Institute of Medicine workshop from 2010 suggested that 30 percent of spending results...

By David Gruber, MD, MBA* | Healthcare spending is forecast to increase from US$3 trillion in 2014 to US$5.2 trillion in 2023, reflecting a compound annual growth rate of 5.9 percent. US healthcare expenditures on a per capita basis are 1.9-2.6 times the amount spent by other developed nations despite having a much younger population. An Institute of Medicine workshop from 2010 suggested that 30 percent of spending...

By Nathan Fish and Frank E. Sheeder A federal court has temporarily enjoined the Texas Medical Board (TMB) from implementing and enforcing a rule restricting the practice of telemedicine pending resolution of an antitrust lawsuit filed by Teladoc, Inc. The temporary injunction represents a small victory for Teladoc, a leading telemedicine provider, in its ongoing legal battle with TMB over the practice of telemedicine...

By Anil Shankar and Adam J. Hepworth The Centers for Medicare and Medicaid Services (“CMS”) released, on May 26, 2015, the a far-ranging proposal for revising the Medicaid managed care regulations (“ Proposed Rule ”). The number of individuals enrolled in Medicaid managed care plans has increased to over 40 million . Federal Medicaid managed care regulations have not been substantially revised...

By Anil Shankar and Adam J. Hepworth The Centers for Medicare and Medicaid Services (“CMS”) released, on May 26, 2015, the a far-ranging proposal for revising the Medicaid managed care regulations (“ Proposed Rule ”). The number of individuals enrolled in Medicaid managed care plans has increased to over 40 million . Federal Medicaid managed care regulations have not been substantially revised...

By Judith A. Waltz The Department of Health and Human Services (HHS) Office of Inspector General (HHS-OIG) has released its Fiscal Year (FY) 2014 Annual Report (Report) on the performance of the Medicaid Fraud Control Units (MFCUs) (OEI-06-15-00010, April 2015). Although the MFCUs reported another strong year in civil recoveries, criminal recoveries were significantly lower than last year, when the MFCUs reported the...

By Jessica Talati On June 1, the Centers for Medicare & Medicaid Services (CMS) released its second annual installment of Medicare reimbursement data for physicians and other practitioners. The data set contains records for more than 950,000 practitioners who received a collective $90 billion in Medicare payments during 2013 calendar year. The physician data consists of information on the number and type of healthcare...

By: Karen Nelson Much has been written about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its repeal of the Sustainable Growth Rate formula for physician compensation and the potential gainsharing safe harbor. But the Act also includes certain Medicare program integrity provisions that may have an impact on health industry providers. These three implications are of particular concern for...