Below is a summary of UPMC-Highmark dispute as of February 22, 2019. This information is limited to litigation proceedings with no discussion about prior contracts or negotiations.
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“Eliminating Kick-Backs and Recovery Act of 2018” (EKRA) is a part of a group of laws recently passed by Congress to expand the law enforcement spectrum available to fight the opioid epidemic. EKRA is part of approximately 70 separate actions referred to as the SUPPORT Act, i.e. Substance Use-Disorder Prevention that Promotes Opioid Recovery and…
A new Telemedicine Act is wending its way through the legislative process in Pennsylvania. Senate Bill 780 of 2017 (attached hereto as a PDF) has been unanimously passed by the Senate and referred to the House Professional Licensure Committee on June 19, 2018. Pennsylvania is one of the few states that does not…
Peer Review Confidentiality will become much more complicated with the addition of economic evaluation to physicians’ quality and efficiency. Physicians will be surprised to learn that many “reviews” to which they may currently be subject to could have “quality implications”, and they should be concerned if those reviews were available to other third parties instead…
On April 23, 2018, CMS issued a request for information on direct provider contracting models. In that request, (attached hereto as a PDF), CMS stated as follows:
“Under a primary care-focused DPC model, CMS could enter into arrangements with primary care practices under which CMS would pay these participating practices a fixed per…
Although it has been almost a decade since the OIG has issued a gainsharing opinion, OIG Advisory Opinion No. 17-09 confirms the federal government’s support of the pay for performance concept.
OIG 17-09 is the first gainsharing opinion issued since the 2015 amendment of the Civil Money Penalty statute (42 U.S.C. § 1328-7a(b)(1)). As you…
In Robie v. Price, Dr. Robie successfully obtained a temporary restraining order prohibiting CMS from terminating his Medicare billing privileges prior to the exhaustion of his administrative remedies by the U.S. District Court for the Sothern District of West Virginia.
As most realize, exhaustion of administrative remedies is usually a prerequisite to further litigation…
The Texas Medical Board and Teladoc have been battling for seven years, and through several rounds of litigation over whether a patient relationship can be established for purposes of providing telemedicine services without an initial face-to-face or in-person visit. This all changed when Texas governor, Greg Abbott, signed Senate Bill 1107, which will take effect…
Emanuele v. Medicor Associates, was presented to the United States District Court for the Western District of Pennsylvania as cross motions for summary judgment, and provides some guidance regarding the Stark requirements for bona fide personal service contracting arrangements.
The case originated as a whistleblower allegation that Hamot Hospital had not complied with all…
On January 12, 2017, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) issued final rules implementing permissive exclusion authorities authorized by the Affordable Care Act expanding exclusion authority under Section 1128 of the Social Security Act. The changes were first proposed on May 9, 2014 at 79 Federal…
