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Carmen Jule is special counsel in the Governmental Practice in the firm's New York office.

Earlier today, the Department of Labor, the Treasury, and the Department Health and Human Services Centers for Medicare and Medicaid Services (the “Departments”) issued a new directive to Certified Independent Dispute Resolution (IDR) Entities regarding issuing payment determinations for certain pending out-of-network (OON) disputes.

Continue Reading No Surprises Act Update: Certified IDR Entities to Resume Payment Determinations for Services Furnished Before October 25, 2022

On February 6, 2023, the United States District Court for the Eastern District of Texas ruled in favor of the Texas Medical Association[1] and vacated portions of the final rule adopted in August 2022 (the “August 2022 Final Rule”) that applied to the Independent Dispute Resolution (“IDR”) process created by the No Surprises Act (the “Act”). [2] The August 2022 Final Rule was adopted by the Departments of Labor, Treasury and Health and Human Services (the “Departments”) and addressed, in part, the specific factors arbitrators must consider in resolving disputes between out-of-network (“OON”) health care providers/facilities and air ambulance providers (collectively, “Providers”), and health insurance plans, under the Act. This is the second time portions of final rules for the IDR decision-making methods have been vacated by this Court as a result of litigation brought by impacted Providers.

Continue Reading Another Win for Providers: Texas Federal District Court Again Vacates Independent Dispute Resolution Rule for the No Surprises Act

On January 31, 2023, the New York State Office of the Medicaid Inspector General (OMIG) released three guidance documents to assist Medicaid providers in meeting the requirements of recently adopted regulations governing (i) the implementation and maintenance of an effective compliance program for certain providers; (ii) Medicaid managed care fraud, waste and abuse prevention programs; and (iii) OMIG’s Self-Disclosure Program for overpayments.

Continue Reading Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program

As surges in various respiratory illnesses – including COVID-19 – loom over holiday gatherings, the Centers for Medicare & Medicaid Services (“CMS”) held an Open Door Forum for skilled nursing facility (“SNF”) providers addressing their obligations to offer/provide COVID-19 vaccinations, vaccination education and COVID-19 treatments, and gave providers the opportunity to bring up questions about obstacles they are facing in achieving compliance with the federal requirements.

Continue Reading Long Term Care Update: As Winter Arrives, CMS Renews its Emphasis on COVID-19 Vaccinations, Bivalent Boosters and Timely Therapeutic Treatments

On Friday, August 26, 2022, the Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”), the Department of Labor’s Employee Benefits Security Administration and the Department of Treasury’s Internal Revenue Service (the “Departments”) published a final rule updating key regulations pertaining to the No Surprises Act (the “Final Rule”). The Final Rule changes requirements promulgated through prior interim final rules[i] to conform with two rulings by the U.S. District Court for the Eastern District of Texas.[ii] The Final Rule addresses specific disclosure requirements for group health plans and health insurance issuers related to the Qualified Payment Amount (“QPA”) for out-of-network (“OON”) services and sets forth the factors and information which certified Federal Independent Dispute Resolution (“IDR”) entities must consider in arbitrating disputes for OON services or items.

Continue Reading Final Rule Changes No Surprises Act Requirements