Providers - For Profit

The ACA turned mistaken overpayments by intermediaries, carriers and Medicaid agencies into potential False Claims Act violations by healthcare providers when it required that an overpayment be reported and refunded within 60 days after it was “identified.”  The ACA does not define what constitutes “identification” of an overpayment, so providers have been left to wonder

Running 324 pages, plus a six-page summary in its pre-release (easy to read) version this massive annual update will be published officially in the November 26, 2014 Federal Register.  Based on something like March Madness bracketology, we narrowed the large, attention-worthy field to these final four.

No. 1:

As previously threatened, HHS will

With group health plan premium increases limited by market and regulatory forces, insurers and self-insurers have raised deductibles, co-insurance, co-pays and other cost-shifting provisions, subject to the ACA’s 2015 maximum out-of-pocket (“MOOP”) limits – $6,600 per individual, $13,200 per family.  But “reference-based pricing” complicates MOOP enforcement.  In Frequently Asked Questions (“FAQ”) guidance issued October 10

In the pre-digital age, if you used “Cliff Notes” in college, you used “nutshells” in law school.  Here’s our “nutshell” version of the U.S. Supreme Court’s June 30, 2014 opinion in Burwell v. Hobby Lobby Stores, Inc., expanding the class of employers that may refuse to provide group health plan contraceptive coverages based on

Recently, we have received requests to re-post prior articles on the 90-day waiting period, the employer mandate final rules (supplemented here, here, here and here), and our pop quiz for ACA consultants.  As we approach our 100th article, some readers apparently find the scroll-down browsing process tedious.  So do we.  Here

We’ve all seen the commercials – “stop taking Fantasima and call your doctor immediately if you notice any of these symptoms . . . .”  If health care regulations came with such warnings, physician unionization should be a listed symptom.

Increasing oversight, declining payment rates and administrative burdens imposed by public and private insurers have

It’s buried deep, in small type, in a set of rules issued almost a year, and thousands of Federal Register pages ago.   Here’s the setup.  Jimmy has a chronic medical problem, and knows it, but he cannot afford insurance payments each month, even with the available subsidy.  So he puts off buying insurance until he

Since our post about East v. Blue Cross and Blue Shield of Louisiana, Et Al., M.D. La. 3:14cv00115, CMS has issued more precise guidance on the subject of third-party premium and cost-sharing payments to insurers, in the form of an interim final rule, effective immediately, codified at 45 CFR § 156.1250:

Issuers offering

We have been concerned for many months that some of our clients and friends are getting unreliable ACA compliance advice.  This is not a knock on insurance agents, or brokers, or TPA’s or any other class of advisors.  We work with some who are as helpful to our mutual clients as we are to them. 

ACA § 1557 (42 U.S.C. § 18116(a)) made several existing non-discrimination laws applicable to “any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies or contracts of insurance, or under any program or activity that is administered by an Executive Agency or any entity established under this title,”