Medicare Advantage Value-Based Insurance Design Model

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CMS, through the Center for Medicare and Medicaid Innovation, announced on September 1, 2015, the introduction of the Medicare Advantage Value-Based Insurance Design (VBID) Model as part of the Health Plan Innovations Initiatives, which are intended to test innovations in health plan design. The VBID Model will test whether the offering of supplemental benefits or reduced cost sharing to enrollees for specified chronic conditions can improve health outcomes and lower expenditures for Medicare Advantage (MA) enrollees. Continue reading this entry

Are FCA Retaliation Claims Against Supervisors, Executives Viable?

CMS Releases Medicare Part B Supplier Billing and Payment Data

When the False Claims Act (FCA) retaliation provision was amended in 2009, the amendment was not explicit as to whether plaintiffs could only recover for retaliation claims against companies, or whether plaintiffs also could bring successful retaliation claims against the individuals within the company alleged to have retaliated, such as supervisors or executives. Federal courts are split on whether retaliation claims against individuals survive motions to dismiss, as most recently shown by two August 2015 federal court decisions that disagree on that issue – United States ex rel. Sibley v. A Plus Physicians Billing Service, Inc. (N.D. Ill.) (finding they could not) and Fitzsimmons v. Cardiology Associates of Fredericksburg (E.D. Va.) (finding the issue of individual liability was more appropriate for evaluation at the summary judgment stage).

While the majority of courts reject individual liability under the FCA retaliation provision and hold that the 2009 amendments were not intended to so extend retaliation liability, not all courts are bending to the weight of the law. Continue reading this entry

Omnibus 340B Guidance Raises New Issues for Covered Entities

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The Department of Health and Human Services (HHS) released its proposed 340B Drug Pricing Program Omnibus Guidance (Omnibus Guidance) on August 28, 2015. The Omnibus Guidance offers comprehensive – and, in some cases, new – guidance for 340B Drug Pricing Program (340B Program) covered entities (including providers such as disproportionate share hospitals, critical access hospitals, and federally qualified health centers), participating drug manufacturers, and other stakeholders, including pharmacies that may contract with covered entities for the distribution of 340B Program drugs (340B Drugs). Continue reading this entry

Telehealth Commercial Coverage and Parity Laws: Trends, Challenges and Opportunities

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There will always be differences among state laws on telehealth coverage, but what is remarkable is the rapidly increasing pace at which states have been adopting coverage statutes in the last few years, with currently 29 states plus Washington D.C. having enacted coverage laws. Here’s what telehealth providers and companies might expect to see from these laws.

Market Segments That Will See Growth

All telehealth market segments can benefit from these laws, depending on how the statutory language is drafted. Healthcare providers offering telehealth-based services can experience growth when these laws are passed, as do software platform developers and manufacturers of telehealth equipment. Continue reading this entry

Will the TELE-MED Act of 2015 Really Change Licensure Rules?

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Congress is reviewing legislation designed to permit telemedicine providers to treat Medicare patients across state lines without the need for separate state licensure. The Telemedicine for Medicare Act of 2015 (S. 1778 and H.R. 3081), known as the TELE-MED Act of 2015, is sponsored by Representative Devin Nunes (R-CA), 15 Republicans and 9 Democrats in the House, and sponsored by Sen. Mazie K. Hirono (D-HI) and Sen. Joni Ernst (R-IA) in the Senate. Continue reading this entry