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Showing 5 posts from June 2015.

On June 25, 2015, the U.S. Supreme Court issued its decision in King v. Burwell, concluding that Congress made premium tax credits available nationwide-on both state-run and HHS-established Exchanges. This is the second challenge to the individual health insurance market reforms of the Affordable Care Act (ACA) to reach the Court and the second ACA opinion to be authored by Chief Justice John Roberts. Previously, in NFIB v. Sebelius, Chief Justice Roberts wrote for the Court in concluding that the ACA's individual mandate was a constitutional exercise of Congress' taxing power. Read More ›

In response to a growing lifestyle disease epidemic over the last several decades, and the resulting adverse impact on employee health and well-being, there is increased interest in employer-based wellness programs, as well as employer-based health clinics. According to RAND Health’s Workplace Wellness Programs Study Final Report (2013), recognizing that these chronic conditions lead to lowered productivity due to absence from illness (absenteeism)and reduced performance even while at work (presenteeism), as well as the associated increase in health care coverage costs and reduced competitiveness in the marketplace, about half of all U.S. employers with 50 or more employees offer workplace wellness programs. Read More ›

On May 26, 2015, the Supreme Court of the United States answered two questions involving the False Claims Act (FCA). On its face, the case before the Court - Kellogg Brown & Root Services, Inc. v. United States ex rel. Carter (KBR)1 - had nothing to do with health care. Instead, the underlying case involved alleged fraud by military contractors in Iraq. However, the answers provided by the Court could have a material impact on members of the health care industry facing investigations and litigation under the FCA. Read More ›

On June 9, 2015 the Office of Inspector General of the Department of Health and Human Services (OIG) issued a fraud alert warning that physician compensation arrangements may violate the federal anti-kickback statute. The fraud alert cautions physicians that they have a responsibility to insure that their financial relationships, such as medical director agreements, are for “bona fide services the physicians actually provide” and that “those arrangements reflect fair market value.” The OIG took the opportunity to publicize that it recently settled cases against 12 physicians who entered into medical director agreements and other arrangements which the OIG believed were for compensation to induce the physicians to refer or direct business to the entity paying the compensation to the physicians. Read More ›

Every health care provider that treats managed Medicaid patients would be impacted financially and operationally under sweeping changes to Medicaid managed care proposed by the Centers for Medicare & Medicaid Services (CMS) on May 26, 2015. This is the first major update to Medicaid managed care in 42 C.F.R. Part 438 in over a decade. The aims to align Medicaid managed care with Medicare Advantage and private market policies, bolster state delivery reforms, impose new quality ratings, set up best practices. The proposed rule directly impacts Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), and Primary Care Case Managers (PCCMs). We have highlighted important issues in the proposed rules affecting healthcare providers here and posted a redline of the proposed changes to the current 42 C.F.R. Part 438 here. Read More ›

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