Written by Gary Bacher and Josh Booth On May 7th and 8th, the Center for Consumer Information and Insurance Oversight (CCIIO) held a public meeting on risk adjustment, the process through which, under the Affordable Care Act (ACA), funds are transferred from health plans that attract relatively low-risk enrollees to plans that attract relatively high-risk enrollees, such… Continue Reading
Category Archives: Payors & PBMs
Subscribe to Payors & PBMs RSS FeedCMS, CCIO, and IRS Release Guidance Proposals on Employer Health Insurance Coverage
Posted in Health Care Reform, Payors & PBMs, UncategorizedWritten by: Gary Bacher and Joshua Booth The Centers for Medicare & Medicaid Services Center for Consumer Information and Insurance Oversight (CCIIO) and the Internal Revenue Service (IRS) recently released four important documents related to the implementation of the Affordable Care Act (ACA) that address employer-provided health insurance plan reporting requirements and the availability of… Continue Reading
OIG Advisory Opinion 12-05 Approves Consumer Rewards Program
Posted in Fraud & Abuse, Health Care Reform, Payors & PBMs, PharmaciesWritten by Theresa Carnegie In OIG Advisory Opinion 12-05, the OIG found that a consumer rewards program (the “Program”) offered by a supermarket chain with in-store and independent pharmacies (the “Requestor”) would not be subject to enforcement under the Anti-Kickback Statute (the “Kickback Statute”) or the beneficiary inducement prohibition found in the civil monetary penalties… Continue Reading
Analysis of Health Insurer-Hospital Vertical Merger Submitted to ABA/AHLA Antitrust in Healthcare Conference
Posted in Antitrust, Hospitals & Health Systems, Mergers, Acquisitions & Other Transactions, Payors & PBMsChristi Braun and Farrah Short have submitted a paper for the 2012 ABA/AHLA Antitrust in Healthcare Conference in which they discuss the proper role of antitrust enforcement in achieving today’s health care reform goals in the context of hospital-health insurer vertical mergers. The paper focuses on the recent acquisition of the West Penn Allegheny Health System,… Continue Reading
CMS Issues Final Rule Impacting Medicare Advantage and Medicare Part D Programs for Contract Year 2013
Posted in Payors & PBMs, ReimbursementWritten by Roy Albert, Susan Berson, and Tara Swenson The Centers for Medicare & Medicaid Services (“CMS”) recently published final regulations implementing program and technical changes to the Medicare Advantage (“MA”) and Medicare Prescription Drug (“Part D”) benefit programs. In the final rule, CMS addressed comments from various stakeholders on the proposed regulations published… Continue Reading
Department of Justice Requires Divestitures to Preserve Competition for Medicare Advantage Plans
Posted in Antitrust, Mergers, Acquisitions & Other Transactions, Payors & PBMs, UncategorizedWritten by: Helen Kim and Robert Kidwell Under a proposed settlement agreement with the Department of Justice (DOJ), private insurers Humana Inc. (Humana) and Arcadian Management Services, Inc. (Arcadian) must divest certain of Arcadian’s assets in parts of five states in order for Humana to proceed with its $150 million acquisition of Arcadian. On March… Continue Reading
FTC Bureau of Competition Chief Testifies on House Bill Affecting Pharmacies
Posted in Antitrust, Payors & PBMs, PharmaciesWritten by Bruce Sokler This morning, on behalf of the Federal Trade Commission (FTC), Bureau of Competition Chief, Richard Feinstein, testified at a meeting of a subcommittee of the House Judiciary Committee concerning H.R. 1946, Preserving Our Hometown Independent Pharmacies Act of 2011, which would create an antitrust exemption for certain collective bargaining by pharmacies. … Continue Reading
New York Court Finds Private Right of Action Under State’s Prompt Pay Law
Posted in Hospitals & Health Systems, Long-term Care/Skilled Nursing Facilities, Payors & PBMs, ReimbursementWritten by Nili S. Yolin On February 22, 2012, a New York State Court held for the first time that a provider may bring a claim against a health insurer under the State’s prompt pay law (PPL). New York’s PPL states that where there is an undisputed obligation to pay a claim, the insurer must… Continue Reading
Summary of Benefits and Coverage: Final Rules Issued, Disclosure Requirements Effective Beginning September 23, 2012
Posted in Payors & PBMs, UncategorizedThe Affordable Care Act creates a new disclosure requirement for group health plans and issuers: the summary of benefits and coverage (SBC). On February 14, 2012, the Departments of Labor, Treasury, and Health and Human Services published final regulations setting forth the required content, timing, and appearance of the SBC. For more information, please see Mintz… Continue Reading
CMS Issues Final Payment Error Calculation Methodology for Medicare Advantage RADV Audits
Posted in Payors & PBMs, State & Federal Audits, Investigations & LitigationWritten by Roy Albert and Susan Berson Thirteen months after over 500 comments were submitted in response to a CMS proposal, Medicare Part C (“Medicare Advantage”) plan sponsors and other stakeholders now know the methodology CMS will use in calculating payment errors through extrapolated estimates in audits based on risk adjustment data validation (“RADV”). On February… Continue Reading
CMS Proposed Rules for Reporting AMP and Best Price May Have Impact Beyond Medicaid Drug Rebates
Posted in Health Care Reform, Payors & PBMs, Pharma & Medical DevicesWritten by Theresa Carnegie, Ellyn Sternfield and Nili Yolin On February 2, 2012, CMS issued proposed regulations that further refine and define how pharmaceutical manufacturers must calculate Medicaid drug rebates in the wake of health care reform (the Proposed Rule). Specifically, the Proposed Rule changes the definition of “bona fide services fee,” which is a key… Continue Reading
HHS, DOL, and IRS Issue FAQs Addressing Automatic Enrollment, Employer Shared Responsibility and Waiting Periods under the ACA
Posted in Accountable Care Organizations, Health Care Reform, Payors & PBMsThe Affordable Care Act will require major changes to the design, maintenance, and operation of employer-sponsored (and other) group health plans. A recently issued set of frequently asked questions (FAQs) from the Departments of Health and Human Services, Labor, and Treasury/IRS provide interim relief in certain instances, and signal the Departments’ thinking as to others. … Continue Reading
Cuomo Issues Executive Order Regarding Limits on Executive Compensation
Posted in Hospitals & Health Systems, Payors & PBMs, UncategorizedWritten by Brian Platton After withdrawing nearly identical proposed legislation one day earlier, on January 18, 2012, New York Governor Andrew Cuomo issued an Executive Order directing certain New York State agencies, including the Department of Health, to promulgate regulations that limit the compensation of executives of entities that receive state funding or payments from… Continue Reading
CMS “Clarifies” Application of Time Limits for Processing Suspect Medicare Prescription Drug Claims
Posted in Fraud & Abuse, Payors & PBMsWritten By Susan Berson and Ellyn Sternfield Over the last several years, the federal government has sought to move from a reactive to a proactive approach to Medicare fraud enforcement. In other words, the hope is to stop fraud before it occurs rather than pay claims and then chase payments that are subsequently determined to… Continue Reading
HHS Issues Bulletin Outlining Essential Health Benefits
Posted in Health Care Reform, Payors & PBMsAs discussed in a previous post published on December 21st, HHS recently released its Essential Health Benefits Bulletin, which outlines the intended regulatory approach to defining the essential health benefits required by section 1302 of the Affordable Care Act. An advisory written by my colleagues Gary Bacher and Alden Bianchi provides a more detailed overview of the Bulletin and its implications.
CMS Requests Comments on Changes to Star Rating Methodology
Posted in Payors & PBMsWritten by Roy Albert and Susan Berson CMS is soliciting comments from Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and other interested parties on its Proposed Methodology for 2013 Plan Ratings (the “Proposed Methodology”). The Proposed Methodology both adds and modifies existing measures used in calculating plan ratings, which are also referred to as “star ratings.”… Continue Reading
Most CMS Audits of Medicare Part D Prescription Drug Plans Revealed Deficiencies, Many Plans Yet to Be Audited
Posted in Payors & PBMs, State & Federal Audits, Investigations & LitigationWritten by Roy Albert and Susan Berson The HHS OIG recently issued a Report concluding that the vast majority of audited Medicare Part D Prescription Drug Plans (PDP) in existence between 2006 and 2009 had problems, many of which resulted from beneficiaries’ coverage status or payment issues. During this same time period, a number of other PDPs were never… Continue Reading
New HHS Essential Health Benefits Bulletin Emphasizes State Flexibility
Posted in Health Care Reform, Payors & PBMsWritten by Gary Bacher and Stephanie Willis On Friday, December 16th, the Department of Health and Human Services (“HHS”)released its Essential Health Benefits Bulletin (the “Bulletin”) that outlines the HHS’s intended regulatory approach to defining the essential health benefits (“EHBs”) required by section 1302 of the Affordable Care Act (the “Act”). As the HHS press release states, the… Continue Reading
New Coalition Formed to Tackle Care for Advanced Illness
Posted in Health Care Reform, Home Health & Hospice, Hospitals & Health Systems, Long-term Care/Skilled Nursing Facilities, Payors & PBMs, PhysiciansWritten by Kevin Kappel Last week a recently formed group called the Coalition to Transform Advanced Care (C-TAC) announced its action plan to improve health care delivery for the sickest and most vulnerable Americans – those with advanced illness. According to C-TAC, advanced illness “occurs when one or more conditions become serious enough that general… Continue Reading
Wisconsin Medicare Part C FCA Settlement for Business Misconduct
Posted in Fraud & Abuse, Payors & PBMs, State & Federal Audits, Investigations & Litigation, UncategorizedWritten by Ellyn Sternfield and Stephanie D. Willis In a Medicare Part C (or “Medicare Advantage”) False Claims Act settlement announced by the Milwaukee-Wisconsin Journal-Sentinel on September 25th, an operator of a Germantown Wisconsin Medicare Advantage plan and its parent agreed to pay $4.8 million to settle allegations that the company improperly paid eligible individuals to… Continue Reading
Innovation Center Extends Bundled Payments Initiative Application Deadlines
Posted in Accountable Care Organizations, Health Care Reform, Hospitals & Health Systems, Payors & PBMs, Reimbursement, UncategorizedWritten by Stephanie Willis The Center for Medicare and Medicaid Innovation has extended the deadlines for submitting letters of intent and final applications for participation in the Bundled Payments for Care Improvement Initiative. On August 23rd, Innovation Center Director Dr. Rick Gilfillan, together with Valinda Rutledge, Director of the Patient Care Models Group, and Senior… Continue Reading
State of New York Forms Task Force Targeting Excessive Compensation at Nonprofits
Posted in Hospitals & Health Systems, Long-term Care/Skilled Nursing Facilities, Payors & PBMsWritten by Nili Yolin New York not-for-profit organizations, including hospitals, nursing homes, and managed care organizations, may need to look beyond the IRS “intermediate sanctions” regulations when setting their executives’ compensation now that Governor Andrew Cuomo’s newly formed Task Force on Not-For-Profit Entities will be reviewing these compensation levels. The Task Force has already begun… Continue Reading
