Healthcare Providers

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Large managed care plans have been squarely in DOJ’s crosshairs for years, but a late July 2023 Justice Department settlement agreement with one regional healthcare provider’s Medicare Advantage Plan offers a glimpse into an issue health systems and providers with their own managed care plans need to track.

This post examines the recent DOJ settlement, analyzes the trend towards enforcement of provider-owned managed care plans, and offers a prediction on what might be coming on the enforcement side.

On February 27, 2023, a jury in Minnesota federal court rendered a verdict in favor of the United States and against a surgical product distributor following a False Claims Act jury trial that lasted six weeks.[1] The jury identified $43 million in Medicare payments flowing from 64,575 kickback-procured claims.

OSHA is currently considering a possible “Prevention of Workplace Violence in Healthcare and Social Assistance” rule. If passed, the Rule would apply to employers whose employees face an increased risk of workplace violence from their patients, clients, residents and/or facility visitors. Such employees include those who work in hospitals, ambulatory medical care or substance abuse…

Executive Order GA-40

On July 26, 2022, Judge Jeremy Kernodle of the Eastern District of Texas affirmed that certain parts of the Interim Final Rule Part II implementing the No Surprises Act (the Act) were invalid. This ruling is nearly identical to Judge Kernodle’s February decision in Texas Medical Association & Corley v. US Dept. of Health and Human Services. This decision vacated a portion of the Interim Final Rule that required arbitrators to give more weight to the out-of-network rate, including what is called the Qualified Payment Amount (QPA), over other permissible factors. The rule’s requirement ultimately contradicted the Act’s direction that arbitrators consider various factors, and not weight any one more heavily than another.

On June 27, 2022, the United States Supreme Court, by a vote of 9-0, overturned the lower circuit courts’ rulings affirming the convictions of two physicians of the unlawful distribution of controlled substances. In Ruan v. United States (Case No. 20-1410), consolidated with Kahn v. United States (Case No. 21-5261), the Supreme Court was asked to determine whether a physician may be convicted of unlawful distribution of controlled substances under 21 U.S.C. § 841(a)(1) without regard to whether, in good faith, the physician “reasonably believed” or “subjectively intended” that his or her prescriptions fall within that course of professional practice. The Controlled Substances Act makes it unlawful for “any person knowingly or intentionally … to manufacture, distribute, or dispense” a controlled substance, “except as authorized.” A prescription is authorized when it is “issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.” 21 C.F.R. § 1306.04(a). The “vague and highly general regulatory language” left open the question of what conduct would fall under the statute’s exception and thus be considered legal.

Health insurance aid cardiogram care chain check

As the health care industry shifts from fee-for-service to value-based arrangements, providers are facing a lot of challenges. A provider’s relationship with payers is often strained by the new business model, and a provider’s ability to collaborate with payers has never been more important.

On this episode of Value-Based Care Insights, host Daniel J. Marino…

Elevating Health Equity

The American Health Law Association released its Special Edition of its Journal of Health and Life Sciences Law on Emerging Issues in Health Equity in the United State: Legal, Legislative, and Policy Perspectives. The association strives to advance public discourse on these issues for the benefit of AHLA members, the public, academia, and decision makers in both the legislative and executive branches of government.

Healthcare Employers

The U.S. Department of Justice’s recent criminal prosecutions of health care executives for no-poach and wage-fixing conspiracies have been met with not-guilty verdicts. Despite these losses, the Department continues to prosecute this conduct, and antitrust enforcers will continue to investigate human resources practices that may restrain competition.

Hospital at Home

The Acute Care Hospital at Home model (ACHAH) provides traditional hospital inpatient acute-level services at home.  Prior to the pandemic a Centers for Medicare and Medicaid pilot study yielded positive results with respect to hospital readmission rates and follow-up emergency department visits. The ACHAH model appears to be a feasible alternative to traditional inpatient acute care that can improve quality of care and patient satisfaction. What was previously a trickle of interest turned into a wave of necessity as the pandemic overwhelmed hospitals and the health care system in 2020. In response to the pandemic, CMS began to provide hospital with broad regulatory flexibility to implement the ACHAH model.