Managed Care Contracting & Provider Payment

New Model Law Requires Cost Estimates & Disclosure of Facility Based Provider Balance Billing

On March 6, 2011, the National Conference of Insurance Legislators (“NCOIL”) finalized model legislation intended to provide consumers with information about balance billing practices of facility-based providers.  More significantly, the law would require health plans to provide enrollees with information about out-of-pocket costs of elective procedures.  The law, if adopted by any state will impose requirements on facilities, facility-based providers and health benefit plans (including health insurers, managed care plans, multiple employer welfare arrangements, an entity that direct-contracts with providers on a risk-sharing basis) to inform patients about balance billing practices by facility-based providers who are out-of-network  with the patient’s health plan.

CMS Seeks Comments on ACO Models

Although we have all been anxiously awaiting the proposed rulemaking defining what CMS will require of an Accountable Care Organization (“ACO”) and how the Medicare Shared Savings Program will work, CMS has asked for additional information from us to assist them with their drafting.

New Hampshire Proposed Insurance Regulations Would Increase State Control over JUA

On May 24, 2010, the New Hampshire Insurance Department proposed changes to the regulations governing the New Hampshire Medical Malpractice Joint Underwriting Association (“JUA”).  These proposed changes are the latest in the ongoing struggle for control over the funds of the JUA.  What follows is a brief history of the issue, followed by a summary of the changes to the rules as proposed by the Department of Insurance.

Health Reform Increases Medicare Advantage Plan Involvement in Hospital Quality

While reviewing the provisions of the Patient Protection and Affordable Care Act, I came across an interesting provision at Section 3201.  Beginning in 2014, Medicare Advantage Plans (“MA Plans”) will receive a quality bonus if their hospital contracts require the hospital to maintain patient safety programs. 

A Few Words about the State Law Addendum

Here is an issue that I have dealt with over and over … on both sides of the table. 

When a Managed Care Organization (“MCO”) uses its form contract in multiple states it often adds different exhibits containing the provisions required by the laws of each state. 

Bill Passed by House that Would Exempt Small Business from Red Flag Rules– Including Health Care Practices with 20 or Fewer Employees

On October 20^th, the House of Representatives passed a bill to amend the provisions of the Fair Credit Reporting Act to exempt small businesses including medical practices with 20 or fewer employees. 

The Red Flag Compliance Train is coming down the Track and Payors are Asleep at the Switch.

Now, as we all know, the deadline for enforcement of the Red Flag Rules is looming … May 1^st.  Providers are struggling to implement red flag compliance policies.  It’s another big PROVIDER compliance panic.

New York Attorney General Reaches Agreement with United HealthCare to Shut Down Ingenix - Aetna also agrees to Discontinue Use of Ingenix

On Tuesday, United HealthCare agreed to the terms of a settlement proposed by the New York Attorney General to end the investigation into the practices if its subsidiary, Ingenix, Inc.  (Link to earlier post about the investigation.)  The settlement, requires United HealthCare to

1st Circuit Upholds New Hampshire Law Banning Disclosure of Physician Prescribing Information

This past November 18^th, the 1^st Circuit overturned a lower Court decision and held that an “innovative” New Hampshire approach aimed at curbing increasing drug prices was not an un Constitutional abridgement of free speech.  The law prevents companies that mine prescription data from selling it to pharmaceutical companies for use by their drug detailers to attempt to influence prescribing patterns. 

Red Flags Rules and What they mean to Health Care Providers

The following is a rather long post, but is an excerpt from a recent talk I gave on the subject.