The status of the independent dispute resolution (IDR) process under the No Surprises Act (NSA) is ever-evolving. Providers are waiting on the sidelines as cases weave their way through the court system. While the IDR process is currently on hold, it is incumbent on providers, payors, and individuals to remain vigilant and stay abreast of the forthcoming changes.
Continue Reading Sheppard Mullin Webinar – No Surprises Act: Litigation Update and Recent Guidance
On August 24, 2023, the United States District Court for the Eastern District of Texas again largely ruled in favor of the Texas Medical Association and other plaintiffs (including air ambulance providers) and vacated certain regulations[1] and related guidance concerning how the “Qualified Payment Amount” (“QPA”) – one of the factors in the arbitration of out-of-network disputes – is calculated under the No Surprises Act (the “Act”).[2] The Court also vacated certain rules specific to the QPA and Federal Independent Dispute Resolution (“IDR”) process for out-of-network air ambulance services.
On August 3, 2023, the United States District Court for the Eastern District of Texas once again ruled in favor of the Texas Medical Association[1] and vacated portions of the guidance related to (i) the administrative fee for the Independent Dispute Resolution (“IDR”) process created by the No Surprises Act (the “Act”) and (ii) the “batching” of claims for the IDR.[2] The Department of Health and Human Services promptly announced that the IDR process is temporarily suspended and will not be available for out-of-network disputes until further notice.
As the nation prepares for the upcoming 2024 elections, the consequences of the U.S. Supreme Court’s ruling in Dobbs v. Jackson continues to be a significant topic of discussion in numerous states. Since that decision and our first and second posts in this series, a number of noteworthy developments* have occurred at both the federal and state levels, including some states passing laws that prohibit or restrict the availability of abortions. Some of the most recent legal developments are summarized below.
As more and more states are enacting privacy laws, organizations in the health care industry may be wondering what the impact these laws will have on them. At this point, there are privacy laws in 12 states, with one more (Delaware) likely to be signed by the governor soon. Those laws are in California, Colorado, Connecticut, Florida, Indiana, Iowa, Montana, Oregon, Tennessee, Texas, Utah, and Virginia. (There is also a new law in Delaware currently pending the governor’s signature). Not all are in effect. Only the laws in California, Connecticut, Colorado and Virginia are effective. The others will go into effect between December of this year and 2026, as follows:
Continue Reading State Privacy Law Roundup: What Health Care Companies Need to Know
On June, 23, 2023, New York City Mayor Eric Adams signed the Healthcare Accountability and Consumer Protection Act (Intro. 844-A). This local law amends the New York City Charter and directs the Mayor to establish an Office of Healthcare Accountability – the first of its kind in the country. Among other things, the NYC Office of Healthcare Accountability will allow New Yorkers to compare costs charged by NYC hospitals for the same services.
Continue Reading New NYC Local Law Promotes Health Care Price Transparency
All types of healthcare providers depend on medical directors to oversee clinical operations and consult with administrative leadership on facility, unit, or clinical service line plans and performance. Medical directors function at the intersection of administration and clinical care, weighing in on matters as varied and important as accreditation, capital expenditures for equipment, staffing, standard operating procedures, and peer review. In addition to clinical skills, they ideally need excellent people skills to balance competing priorities and communicate effectively with different stakeholders. They are a valuable resource and partner for compliance professionals. With proper support, medical directors can support an organization’s compliance efforts and help mitigate risk for both employee issues and healthcare regulatory matters. This article outlines five key best practices in contracting for medical director services:
Continue Reading Do Your Medical Director Arrangements Meet the Top Five Best Practices?
Yesterday, the Supreme Court issued a unanimous decision holding that the aggravated identity theft statute –and its mandatory minimum of two years – is not triggered merely because someone else’s identification facilitates or furthers the offense in some way. See Dubin v. United States. We have seen a growing trend of the government adding aggravated identity theft in healthcare fraud cases. As a result of this decision, we may see that statute far less.
Continue Reading Is this “Good-Bye” to the Two Year Mandatory Minimum in Healthcare Fraud Cases?
Yesterday, the Supreme Court issued a unanimous decision holding that the scienter element of the False Claims Act (“FCA”) is met if a defendant subjectively knew his or her claims were false and submitted them anyway. See United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway. The Court’s ruling was narrow and avoided the more challenging—and common—issues raised during oral argument (which we previously discussed here).
Recently, we were invited to speak on a panel at the Executive War College on Diagnostics, Clinical Laboratory and Pathology Management. We spoke about the federal information blocking rules, and highlighted how some actors are still engaging in conduct that the rules were intended to discourage, in part due to the lack of enforcement rules.
Continue Reading Laboratory and Pathology Information Blocking Concerns
Companies regularly are required to interpret ambiguous and vague regulatory provisions. Today, the United States Supreme Court heard oral arguments in a pair of consolidated cases to determine whether a defendant’s subjective interpretation of an ambiguous regulation is relevant to determining the knowledge (or scienter) element of the False Claims Act or, as the Seventh Circuit held in the case below, that once a defendant can articulate an objectively reasonable interpretation its contemporaneously held subjective belief is irrelevant to the knowledge inquiry. The issue is a significant one for both the government and relators on one side, and potential defendants on the other, as False Claims Act (FCA) liability imposes treble damages and penalties exceeding $20,000 per claim as well as relators’ attorneys’ fees and costs.
Continue Reading Supreme Court Hears Arguments on False Claims Act Scienter Standard