Perspectives on Managed Care, Payer Disputes and Reimbursement
10 total results. Page 1 of 1.
On July 1, 2021, the Departments of Health and Human Services, Labor, and Treasury, and the Office of Personnel Management, released a much-anticipated interim final rule designed to protect Americans from surprise medical bills.
States seeking to regulate pharmacy benefit managers (PBMs) and prescription drug pricing received a win from the Supreme Court, which reversed an Eighth Circuit decision that had invalidated an Arkansas law governing pharmacy and PBM conduct on ERISA preemption grounds.
11th Circuit Upholds Rights of Medicare Advantage ‘Downstream Actors’ to File Suit under the Medicare Secondary Payer Act
Calling it a “straightforward inquiry,” the US Court of Appeals for the 11th Circuit recently opted to expand access to the Medicare Secondary Payer Act (the MSP Act) private right of recovery to Medicare Advantage “downstream actors.”
The Sixth Circuit has issued an important decision that condemns plan provisions that provide different benefits based on a patient’s need for continued dialysis, even if the provision applies to all dialysis patients and not just those with end-stage renal disease (ESRD).
Last month, in Pharmaceutical Care Management Association v. Tufte et al. No. 18-2926 (8th Cir. August 7, 2020), the United States Court of Appeals for the Eighth Circuit invalidated legislation in North Dakota on the grounds that it was preempted by ERISA.
Medical providers treating patients covered by ERISA-governed health plans on an out-of-network basis can assert state-law claims to hold plans to their payment promises without running afoul of ERISA’s preemption provision (ERISA § 514(a), 29 U.S.C. § 1144(a)).
For health care providers that are out-of-network with a patient’s insurance, navigating reimbursement is a tactical imperative. The current economic environment makes it more difficult for patients to pay coinsurance, while insurers are increasingly motivated to cut expenses.
Below are six reimbursement issues that health care providers should be on “high alert” for as the COVID-19 crisis persists.
“Save the ER for emergencies – or you’ll be responsible for the cost.” This warning was included in a 2017 letter Blue Cross and Blue Shield of Georgia, Inc. (BCBS) sent to its insureds, alerting them to a new policy for reviewing and paying emergency room medical claims.
Lawmakers remain in negotiations among the three key committees in the House of Representatives: Energy & Commerce, Ways & Means, and Education & Labor, along with the Senate Committee on Health, Education, Labor and Pensions (HELP), about the best way to address surprise medical bills.