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Showing 11 posts in Managed Care.

California’s Department of Managed Health Care (“DMHC”) recently finalized regulations that significantly expand what it means to take on “global risk,” which triggers the requirement to obtain a Knox-Keene license or an exemption. Historically, the requirement to obtain a Knox-Keene license has been reserved for health maintenance organizations (“HMOs”) or other organizations that are paid on a capitated basis in exchange for providing or arranging health care services.

The new regulation will disrupt this status quo by sweeping in a range of value-based payment arrangements – potentially including independent practice association (“IPA”) participation in hospital risk pools and some accountable care organizations (“ACOs”) – that providers have historically entered into without needing to be licensed as a Knox-Keene plan. California-based providers that engage in these types of payment arrangements should therefore pay special attention to these new rules as they are implemented. Read More ›

On February 4, 2019, the California Court of Appeal affirmed a judgment awarding plaintiff, Dr. Kenneth Economy, substantial damages for his suspension and subsequent termination of his staff privileges at defendant Sutter East Bay Hospitals. The Court of Appeal held that, because Dr. Economy’s termination, even though done under the provisions of an exclusive contract, was based on “medical disciplinary cause or reason,” he was entitled to prior notice and a hearing in accordance with Business and Professions Code section 809 et seq. This decision flies in the face of the underlying premise for exclusive contracts: the ability for a hospital to enter into a contractual arrangement that allows it to set superior metrics in exchange for exclusive rights to provide services. Clinical issues have long been mandated to be within the purview of the medical staff but exclusive contracting gives hospitals the ability to contract for higher standards of quality of care. The severity of the Economy decision calls into question the accepted approach to exclusive contracts. Read More ›

The Department of Managed Health Care (DMHC) recently published a regulation that could dramatically expand the scope of arrangements that are considered health care service plans for which a license is required under the Knox-Keene Act, the legal framework for managed care in California. Read More ›

Hooper Lundy & Bookman has learned that Anthem Blue Cross is attempting to apply a Commercial Outpatient Prospective Payment System (COPPS) to commercial outpatient hospital services and is including provisions in amendments in its Facility Agreements to implement this program. Read More ›

On April 27, 2018, the U.S. Department of Health and Human Services, Department of Labor, and the Treasury Department (collectively the Departments) issued a “Clarification” of its previously-issued Greatest of Three (GOT) rule regarding payment for out-of-network emergency services.  While the immediate impetus was a court order requiring the Departments to clarify the basis for the GOT rule, the Departments have provided valuable guidance that will assist providers in challenging the level of payment for such services. Read More ›

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