U.S. DOJ sues to stop health plan mergers

gavel-scales2013%20052[On Wednesday, July 20, 2016, the U.S. Department of Justice (DOJ) filed two lawsuits in the U.S. District Court for the District of Columbia, one, Cause 1:16-cv-01494, seeking to stop the proposed merger between Aetna and Humana (valued at $37 billion) and the other, Cause 1:16-cv-01493, seeking to stop the acquisition of Cigna by Anthem (valued at $54 billion). Continue Reading

Congress’ suggestions for ransomware treatment under HIPAA

dataLocks148650499Backing up electronic health record data may become an important aspect of complying with and mitigating risk under the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) if the U.S. Health and Human Services Office of Civil Rights (OCR) heeds legislators’ recommendations. Continue Reading

Branding 101 – Trademark Descriptive Fair Use

curtains_000003766048Small1-001-300x199Last week we discussed ways that you can use a competitor’s mark in comparative advertising. This week we will discuss use of a mark in a descriptive manner such that it is not being used as a trademark, thereby greatly reducing, if not eliminating, the possibility of the use being found to be trademark infringement. Continue Reading

Compensating non-exempt employees using the fluctuating workweek method

Pay DayEmployers often misconstrue the terms “non-exempt employee” and “hourly employee,” leading them to believe the terms are interchangeable. But, not all non-exempt employees are necessarily hourly employees. The Fair Labor Standards Act (FLSA) allows employers to pay their non-exempt employees on a salary basis as long as they meet minimum wage and overtime mandates. Paying certain non-exempt employees on a salary basis may prove a useful tool as healthcare institutions weigh changes in employee compensation practices necessitated by new FLSA regulations (previously discussed). Continue Reading

New standard of proof for implied certification liability under FCA

flag_160540827The Supreme Court’s unanimous decision in Universal Health Services, Inc. v. United States ex rel. Escobar, No. 15-7 (U.S. June 16, 2016) upholds the viability of the implied certification theory of False Claims Act liability. But it also makes cases arising from minor instances of noncompliance much harder to prove. The Court held that a knowing failure to disclose a violation of a material statutory, regulatory, or contractual requirement can create False Claims Act liability. The requirement need not be an express condition of payment, but it must be material to the government’s decision to pay. Continue Reading

How to buy distressed healthcare assets

HealthcareHorizonsOver the last several years, many healthcare providers have struggled financially due to decreased reimbursements and changing payment models. Hardest hit are providers in small towns that do not benefit from being part of larger healthcare systems. Seeking relief, they may initiate Chapter 11 bankruptcy proceedings and sell assets to third parties to relinquish liabilities. Continue Reading

Texas Medical Board Proposes New Call Coverage Rules for Telemedicine and Traditional Patient Care

On June 9, 2016, the Texas Medical Board proposed for comment new rules regarding physician call coverage. The proposed new rule originated from the Board’s Telemedicine Committee and changes the current telemedicine call coverage rule. The rule would apply to all physician call coverage relationships, not just telemedicine.

During the meetings last week, the Board’s Executive Director stated that the proposed rule was created at the request of the Texas Medical Association and leadership from Children’s Medical Center of Dallas with input from the Texas e-Health Alliance. An earlier draft was withdrawn during the Board’s March 2016 meeting. The current draft was reviewed and discussed during a recent meeting of the Board’s telemedicine stakeholder group. Continue Reading

Out-of-network still in business

gavel-scales2013%20052[The out-of-network (OON) business model faces challenges as the result of changes to health and benefit plan OON coverage, but a ruling by Judge Hoyt of the U.S. District Court for the Southern District of Texas suggests that health plans should be careful in refusing payment based on perceived OON high charges, questions about OON co-insurance collection, or provider financial arrangements. Continue Reading

Court Tells FTC in Hershey to Kiss Off

On May 9, 2016, the Middle District of Pennsylvania in FTC et al. v. Hershey Medical Center et al. (“Hershey”) denied a preliminary injunction request by the FTC to block a merger between Penn State Hershey Medical Center and PinnacleHealth System. The District Court rejected the FTC’s request based on its finding that the FTC’s geographic market definition was “unrealistically narrow and does not assume the commercial realities faced by consumers in the region.” The proper geographic market is one from which the defendant hospitals draw the bulk of their patients, with few patients entering in from outside that area to seek medical care and few patients within that area leaving to seek care from other hospitals. The District Court found the FTC’s proposed geographic market to be “starkly narrow,” particularly “given the realities of living in Central Pennsylvania, which is largely rural and requires driving distances for specific goods and services.” By failing to set forth a relevant geographic market, the District Court held that the FTC could not demonstrate a likelihood of success on the merits of its Clayton Act case against the merger and denied the preliminary injunction. Continue Reading

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