Patient Protection and Affordable Care Act

On January 5, 2015, Commissioner Dave Jones issued emergency regulations affecting health insurers with respect to access to provider networks in response to consumer complaints that appointments with physicians are hard to obtain, that in-network care is far away, and that in-network provider directories are inaccurate.
Continue Reading California Insurance Commissioner Issues Emergency Regulations Affecting Narrow Provider Networks

As of January 1, 2015, the Patient Protection and Affordable Care Act (ACA-otherwise known as Obamacare) begins to impose certain health coverage requirements on employers who have at least 50 employees. Even though its implications are almost one year away, it is not too soon for employers to prepare for the Employer Mandate. Employers would be wise to figure out if the mandate applies to them, understand the potential penalties that can be imposed on them and, taking into account all of the various considerations, decide if they want to pay or play.
Continue Reading Preparing for the Affordable Care Act Employer Mandate

New amendments to California’s local health care district law require districts to obtain a fair market value appraisal if the district transfers fifty percent or more of its assets (in sum or by increment) to one or more nonprofit corporations for less than fair market value, and disclose the fair market value of such assets to the voters for approval of the transfer. These amendments were enacted by SB 804, which Governor Brown signed into law on September 28, 2012.
Continue Reading SB 804 Requires California Local Health Care Districts To Obtain Fair Market Value Appraisals In Certain Asset Transfers

By Karie Rego

As California transitions faster than other parts of the country into more and more managed care payment arrangements, the challenges and pitfalls related to payment increase. Thus, providers must identify risks and implement safeguards to protect payments.

New coding issues can require additional attention. Even though in some ways coding is simpler than traditional fee-for-service, in other ways there is a complicated learning curve and the potential of increased government scrutiny. Medicare Advantage, new ACO arrangements and many commercial contract payments are based on the patient’s diagnosis.Continue Reading Payment Safeguards for Provider Managed Care Arrangements

The Department of Justice and Federal Trade Commission recently proposed new guidelines regarding antitrust enforcement of accountable care organizations — the new health care delivery model mandated by the 2010 Patient Protection and Affordable Care Act (PPACA) pursuant to its “shared savings program.” This statement was issued in conjunction with the Department of Health and Human Services’ Centers for Medicare and Medicaid Services’ (CMS) proposed regulations implementing the shared savings program, as part of a coordinated interagency effort to facilitate health care provider participation in the shared savings program, so as to achieve the cost savings and improvement in quality of care Congress intended.
Continue Reading Levels of Antitrust Scrutiny for ACOs

By Lynsey Mitchel

The California Department of Managed Health Care (“DMHC”) is currently considering the regulatory landscape for Accountable Care Organizations (“ACOs”) in California. At a public meeting on January 19, 2011, the DMHC announced it will most likely require ACOs to be licensed. ACOs, created by a provision in the healthcare reform law, encourage care coordination by allowing physicians to integrate with other members of the health care system in order to reduce unnecessary costs and improve the quality of care for Medicare fee-for-service beneficiaries. On December 3, 2010, officials from the Centers for Medicare and Medicaid Services (“CMS”) announced they expect to issue proposed regulations for ACOs by mid-January 2011. To date, no regulations have been issued.Continue Reading California’s Department of Managed Health Care Announces ACOs Should Expect Licensure Requirement

By Ken Yood and Lynsey Mitchel

On September 23, 2010, the Centers for Medicare and Medicaid Services ("CMS") released its Voluntary Self-Referral Disclosure Protocol ("SRDP") that healthcare providers and suppliers can use to disclose violations of the physician self-referral statute or Stark Law (Section 1877 of the Social Security Act). The protocol potentially offers promising incentives for self-disclosing, but providers and suppliers must be aware of its attendant risks and burdens. Numerous and complex factors should be considered when a provider contemplates self-disclosing pursuant to the SRDP. 
 Continue Reading CMS Releases Self-Referral Disclosure Protocol for Stark Violations

By Courtney Mathes

The new healthcare laws signed by President Obama on March 23rd and 30th, and specifically the Patient Protection and Affordable Care Act (PPACA), includes a significant modification to the "in-office ancillary services" exception of the Stark Law.  Physicians who refer patients for MRI, CT or PET services, to an entity in which the referring physician has a financial interest, including the physician’s own office or medical group, must now provide written notice to the patient of the patient’s ability to utilize an alternative supplier. Additionally, the notice must include a list of alternative suppliers. This amendment not only applies to referrals to a separate entity, but it also applies to referrals within a group practice.Continue Reading New Healthcare Law Requires Financial Disclosures By Referring Physicians