In my recent Massachusetts Health & Hospital Association (MHA) webinar, “Strategies for Avoiding Medicare and Medicaid Fraud in 30 Minutes Webinar,” I discuss Medicare/Medicaid fraud (unintentional or otherwise), overbilling, “upcoding” (CPT codes), as well as the government’s current investigative/prosecutorial priorities, such as the Department of Justice’s crackdown on illicit telemedicine businesses. Enjoy the webinar recording here: https://bit.ly/3BrgzO4
On Friday, June 24, in Dobbs v. Jackson Women’s Health Organization, the United States Supreme Court overruled Roe v. Wade and held that the United States Constitution does not protect a woman’s right to terminate her pregnancy. To learn more about the potential impact of Dobbs on Employer-Sponsored Health Plans, please visit our Labor and Employment Legal Insights blog: https://www.laborandemploymentlawinsights.com/2022/06/potential-impact-of-dobbs-on-employer-sponsored-health-plans/
On April 24-26, The National Association of Accountable Care Organizations held its semi-annual conference for members. NAACOS invites its business partner members, including Husch Blackwell, to attend their semi-annual meetings. Scott Loftin, a Healthcare Regulatory Associate in Husch Blackwell’s Denver office, and I were fortunate enough to attend the conference on behalf of the firm. This conference provided an opportunity for us to listen to the issues, challenges, concerns, and ideas ACO leadership are exploring and facing in today’s regulatory landscape. The presentations and conversations among the members provided us with a deeper understanding of our ACO clients’ business and legal needs. Continue Reading Husch Blackwell at the NAACOS Conference
The Trump Administration’s latest effort to limit the power of pharmacy benefit managers (“PBMs”) is marred by economic uncertainty and looming legal scrutiny. The Office of Inspector General (“OIG”) within the Department of Health and Human Services (“HHS”) recently released a proposed rule (“proposed rule”) removing safe harbor protection under the Anti-Kickback Statute (“AKS”) for prescription drug rebates (“drug rebates) paid by a manufacturer to Medicare Part D plan sponsors and Medicaid managed care organizations (“MCOs”) or their PBMs. The rule also creates new safe harbor protections for point-of-sale reductions in price and certain PBM services fees. The long-awaited proposed rule follows months of anticipation after the Trump Administration released its May 2018 Blueprint to reduce prescription drug costs.
PBMs in Brief
PBMs, on behalf of health plans, employers, and other entities, negotiate and contract with drug manufacturers to obtain rebates on prescription drugs dispensed to health plan members. By aggregating their collective scale and purchasing power of all health plan or employer group clients, PBMs can negotiate better deals with the manufacturer than any one plan or group operating independently. Rebates are typically negotiated on brand-name drugs that compete with therapeutically-similar brands and generics. These retroactive rebates (after point-of-sale) are based on a multitude of factors, including a drug’s placement in a plan formulary designed by the PBM, and the PBM’s power to increase a manufacturer’s market share for specific drugs by inclusion on a formulary. A manufacturer may provide a greater rebate if its product is included in a “preferred” position on the PBM formulary. Continue Reading HHS Targets PBMs But May Exceed Its Legal Authority in Proposed Rule Eliminating AKS Protection for Drug Rebates
Courts recognize the complication that exists when determining what constitutes actionable harassment where a healthcare employee is a caretaker for a patient with diminished capacity. The Fifth Circuit Court of Appeals recently reviewed this issue in a Title VII case that highlights the risks posed to employers in the healthcare and social assistance industries by patient harassment and violence: Gardner v. CLC of Pascagoula, LLC, No. 17-60072 (February 6, 2019). In Gardner, the Fifth Circuit explained the risks to healthcare employers when it reversed summary judgment on a nurse assistant’s claim for hostile work environment and retaliation, holding that a genuine dispute of material fact existed as to whether an assisted living facility took reasonable precautions to prevent sexual harassment and physical violence by a resident.
Gardner was a Certified Nursing Assistant employed at the Plaza Community Living Center, an assisted living facility, and “often worked with patients who were either physically combative or sexually aggressive.” Gardner had been assigned to work with a patient who had been diagnosed with multiple “physical and mental illnesses,” and had a reputation for groping female employees, as well as a history of violent and sexual behavior toward both patients and staff at the facility. Gardner alleged that she put up with propositioning and sexual assault by the patient on a regular basis, but that when she complained to the administrator at the facility, she was told to “put [her] big girl panties on and go back to work.” Continue Reading Fifth Circuit Rules Harassment By Patients In The Healthcare Industry Deserves Special Consideration, But Employer May Still Be Liable
When Title IX of the Education Amendments of 1972, 20 U.S.C. § 1681, et seq. (“Title IX”), which prohibits many forms of discrimination on the basis of sex, appears in the news or on social media, we typically associate it with traditional colleges and universities. But recent case law suggests that Title IX likely applies to a broader set of institutions, including, under certain circumstances, some hospitals.
Over the years, an extensive body of federal case law and regulation has arisen around Title IX, imposing detailed requirements on institutions concerning how they must respond to and investigate complaints, how complaints must be adjudicated and the nature of appropriate remedies. Moreover, these regulations also have recently been in flux. As a result, Title IX compliance often requires significant institutional resources and constant vigilance.
Because compliance with Title IX requires significant attention from the institution, it is critical that hospitals determine whether they meet the developing criteria to be subject to the requirements of Title IX and, if so, whether they have in place the proper policies, procedures and personnel to ensure compliance. In this article, we describe those criteria and provide a brief summary of the broader legal context. Continue Reading Do the Detailed Federal Requirements for Addressing Sex Discrimination Apply to Your Hospital?
Under Texas law, physicians that will be called upon to complete and sign a death certificate in Texas are required to register to file the certificate electronically with the Texas Department of State Health Services. The Texas Medical Board is authorized to take action against providers who do not register for electronic filing of death certificates under Tex. Health and Safety Code §193.005. Until recently, registration and filing of death certificates was made through the Texas Electronic Registrar (“TER”).
On January 1, 2019, the Texas Department of State Health Services replaced TER with a new platform, the Texas Electronic Vital Events Registrar (“TxEver”). TxEver supports all vital events operations, including reporting, registration, and amendments of birth and death records, and represents one of the first fully integrated vital records systems nationwide. TxEver will additionally support the Texas remote birth issuance system, which allows users to obtain copies of birth certificates without having to visit the vital records offices in their county of birth. Continue Reading New fully integrated record system, TxEver replaces Texas Electronic Death Registrar
Hospitals are not happy with CMS’ recent changes to hospital outpatient payments. Two hospital associations and three hospitals claim in a federal lawsuit filed December 4, 2018, that CMS had no authority to change the payment scheme for off-campus provider-based departments (PBDs). The change took effect January 1, 2019, and is estimated to reduce payments to hospitals by $380 million in the first year of a two-year phase-in period.
The plaintiffs, including the American Hospital Association and the Association of American Medical Colleges, are seeking judgment that the payment change is unenforceable as well as preliminary and permanent injunctive relief. The complaint against US Department of Health and Human Services Secretary Alex Azar was filed in the U.S. District Court for the District of Columbia.
The plaintiffs’ assert that the reduced payments threaten patient access to care and harm the providers’ ability to meet the health care needs of their patients, including some of the most vulnerable populations. Continue Reading Hospitals React Strongly to CMS’ Changes to Hospital Outpatient Payments
The regulation of pharmacies at the state level might not be what Justice Louis Brandeis had in mind as an example of a “laboratory of democracy,” but for pharmacists and consumers, state-level policy-making can have important real-world effects and encourage efforts on the federal stage. Over the past twelve months a number of regulatory trends have played out that define the current operating environment for pharmacies, many of which are anticipated to continue in 2019. Continue Reading Recent Developments in State Pharmacy Law & Regulation: Looking Back at 2018 and What to Expect in 2019
This is the third article in our series on the new “Pathways” rules for Accountable Care Organizations. Our first two articles in the series can be found here.
The Centers for Medicare and Medicaid Services (CMS) issued its anticipated final rule revising the Medicare Shared Savings Program to improve cost savings and quality.
With the changes in the final rule, the revamped program, called “Pathways to Success,” is projected to save Medicare $2.9 billion over 10 years—that’s $0.7 billion more than projected in the proposed rule issued August 9, 2018. Continue Reading The “Pathways to Success” Final Rule is Here: ACO’s Face Big Decisions