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Keeping you afloat amidst the rising sea of regulations

Supreme Court Unlikely to Adopt Automatic-Dismissal Rule for Violations of False Claims Act’s Seal Requirement

On November 1, 2016, the Supreme Court heard argument in State Farm Fire & Casualty Co. v. United States ex rel. Rigsby, a False Claims Act case in which the defendant sought dismissal of a qui tam action after the whistleblower violated the FCA’s seal requirement, 31 U.S.C. § 3730(b)(2), and publicly disclosed the complaint. See the oral-argument transcript here.

Mylan Agrees to $465 Million Settlement with DOJ Over EpiPen Medicaid Drug Rebate Reporting Classification

Mylan recently announced a $465 million settlement with the US Department of Justice and other government agencies regarding the company’s covered outpatient drug (COD) classification of its EpiPen (and EpiPen, Jr.), an epinephrine auto-injector, under the Medicaid Drug Rebate Program (MDRP).

Goodbye and Good Riddance: CMS Proposes to Eliminate 2-Midnight Policy Payment Reduction

On April 27, 2016, the Centers for Medicare & Medicaid Services published a proposed rule that, among other things, would eliminate the 0.2 percent inpatient payment reduction resulting from the “2-Midnight Rule." CMS estimates that eliminating the payment reduction would yield an additional $539 million in reimbursements in Fiscal Year 2017, a significant benefit for hospitals.

CMS’s Long-Awaited Final 60-Day Repayment Rule Provides Guidance and Eases Some Requirements for Health Care Providers and Suppliers

On Friday, February 12, 2016, the Centers for Medicare and Medicaid Services (CMS) released the long-awaited Final Rule and regulations,[1] providing much needed guidance to providers and suppliers on how to meet the Affordable Care Act’s (ACA’s) 60-day overpayment mandate.[2] Specifically, a provision enacted as part of the ACA in 2010 requires that all Medicare and Medicaid overpayments be reported and returned by the later of (i) 60 days after the date on which the overp

Medical Providers: How NOT to State an ERISA Claim

The 7th Circuit just denied ERISA rights to medical providers, but this doesn’t have to be the result. On October 1, 2015, the Court of Appeals for the Seventh Circuit issued a decision holding that in-network chiropractors were limited to the remedies available under their network contract with Blue Cross and could not invoke rights under the Employee Retirement Income Security Act (ERISA).

Supreme Court Blocks Path for Health Care Providers Seeking Additional Medicaid Funding

On March 31, 2015, the Supreme Court of the United States issued a 5-4 decision in the case of Armstrong v. Exceptional Child Center, Inc., 575 U.S. __ (2015), holding that health care providers do not have the right to sue a state Medicaid program under Section 30(A) of the federal Medicaid Act (Section 30(A)) for injunctive relief.

Report Suggests CMS Should Modify Requirements for Claims Repayment

In a March 19, 2015 report commissioned by the American Orthotic & Prosthetic Association (AOPA), a health care consulting firm found that the Center for Medicare & Medicaid Services (CMS) could save $12 million over 10 years by not requiring providers to repay disputed Part B claims to Medicare until after the Administrative Law Judge hearing and determination. This change in policy also could make a tremendous difference to provider operations since it would allow them to have access to certain funds during the very lengthy period while they wait for the ALJ determination.

Cutting Class: California Health Provider Overcomes Class Action Treatment of Patient Billing Claims

In a decision that is good news for California hospitals, the California Court of Appeal invalidated class certification when a San Diego-based hospital system proved that the only way to determine the members of an uninsured patient class was to review more than 120,000 patient records. In Hale v. Sharp Healthcare, the California Court of Appeal, Fourth Appellate District affirmed the trial court’s order decertifying a class of uninsured patients claiming unfair billing practices.

Last Chance: New Way for Hospitals to Participate in the CMS Settlement Offer for Inpatient Claims

In an effort to encourage hospitals to take advantage of the 68 percent settlement offer for previously denied inpatient claims, [1] the Centers for Medicare and Medicaid Services (CMS) recently announced a new procedure. Hospitals that are unable to produce the required list of claims eligible for settlement by October 31, 2014 (this Friday), may instead submit a request to CMS for a list of potentially eligible claims (a “potentials list”).

Hospital System Responds in ‘Reverse False Claims Act’ Overpayment Suit

As part of a case we continue to follow, in which the US Department of Justice (DOJ) intervened in a False Claims Act (FCA) suit against Continuum Health Partners and Mount Sinai Health System, the defendant hospital system recently filed a motion to dismiss the DOJ’s complaint-in-intervention. In the motion to dismiss, the hospital system argued that the government failed to state a claim in arguing that the health care providers did not repay alleged overpayments within the 60-day period required by the FCA.