In a bold and seemingly unprecedented move, Aetna recently sued several California surgery centers for an alleged “fraudulent billing scheme”.  The lawsuit alleges that the surgery centers induced physicians to refer patients to the surgery centers with promises that the patients would not have any financial responsibility for their coinsurance and deductibles.  Aetna claims that the surgery centers then turned around and submitted charges for reimbursement that were artificially inflated driving up the cost of health insurance coverage.

Aetna’s lawsuit alleges that providers are liable for engaging in a fraudulent and illegal kickback scheme when they waive a patient’s coinsurance and deductible amounts, even if the provider bills the patient but ultimately does not collect from the patient.  Aetna is asking the court to require the surgery centers to pay damages, to disgorge their profits, and pay Aetna’s attorney fees.  Aetna is also asking the court to issue an injunction preventing such “fee-forgiving” practices, in the future.

Aetna’s theories of liability are somewhat novel and it remains to be determined if they will be successful.  Providers should be aware that insurers are increasingly using aggressive litigation tactics to challenge unauthorized discount arrangements between providers and patients.  As a result of increased scrutiny by third party payors with respect to charges and waivers of co-pays and deductibles, providers should review their billing and collection practices to ensure contractual, legal and regulatory compliance.

On February 21, 2012, CMS announced its first award of repayable loans to seven Consumer Operated and Oriented Plans (CO-OPs).  The awards will help CO-OPs establish private, non-profit, consumer-governed health insurance companies with the goal of expanding health insurance options for consumers and small businesses.  The CO-OPs will eventually operate in each states’ health insurance exchange under the Affordable Care Act, but will also offer plans outside of the exchange.  Starting on January 1, 2014, the first seven CO-OPs will become operational in eight states. 

On January 17, 2012 the Centers for Medicare & Medicaid Services (“CMS”) adopted as a final rule changing Medicare’s Extra Help Program.  The Extra Help Program is a prescription drug coverage low-income subsidy created through the Affordable Care Act (“ACA”).  Effective January 18, 2012, the final rule incorporates the ACA’s changes to the Extra Help Program by extending eligibility for one year after the death of a beneficiary’s spouse that would otherwise decrease or eliminate the subsidy.  The final rule also implements changes to the Medicare Improvements for Patients and Provider Act of 2008 by excluding from a resource (for purposes of Extra Help eligibility) the value of life insurance policies or income for food, shelter, and certain household bills.   

Read the full notice from the federal register here.    

As the holiday season continues to heat up, many hospital and medical group practice administrators may have missed an important change in the creation of the health insurance exchange under the Affordable Care Act.  The issue concerns how the “essential health benefits” under the health insurance policies to be offered under the health insurance exchanges would be determined.  Initially, this was to be determined by Health and Human Services.  However, in a recently issued regulation, HHS determined that each state could determine what constitutes “essential health benefits” for the health insurance policies offered to individuals and to small groups.  Many providers have not followed this debate because very few states have decided to participate in the health insurance exchanges.  However, for those states that are participating, hospitals and physicians need to get into this debate.

On February 24, 2011, the U.S. Department of Health and Human Services (HHS) announced that states can begin to apply for a second round of grants, which they can use to create or improve existing health insurance premium review programs. Approximately $200 million is available to states to better track and review premium rate increases, and make the rate process more transparent to consumers. HHS anticipates that the state review programs will also enable states to challenge or even prevent unreasonable premium increases from being implemented. This round of grants marks the federal government’s continued effort to combat rising health insurance premiums.

To read more about this announcement and to see how to access grant funding, please go to http://www.healthcare.gov/news/factsheets/ratereview02242011a.html.

On January 20, 2011, the Department of Health and Human Services (HHS) announced an additional grant funding opportunity for states to establish their health insurance exchanges. Two types of grants will be available: Level One and Level Two. Level One grants will provide states with funding for up to one year, and subsequent to the first year, states may apply for a second year of Level One funding. Level Two grants, which provide states with funding through December 31, 2014, are available for those states that are further along in the implementation of their exchanges. For states to receive funding at either level, they must submit plans to HHS outlining how they intend to implement the exchanges along with anticipated expenditures. HHS did not disclose the amount of funding available for the grants, but it noted that funding will vary based on state need. For additional information regarding the grants, please see the Health Insurance Exchange Establishment Grants Fact Sheet.

The U.S. Department of Health and Human Services (HHS) today announced new Consumer Assistance Grants program awards of nearly $30 million to help states and territories put patients in charge of their health care. These grants will support states' efforts to establish or strengthen consumer assistance programs that provide direct services to consumers with questions or concerns regarding their health insurance.

• Health insurance coverage offered by health insurance issuers
• Medicaid coverage
• Children's Health Insurance Program (CHIP) coverage
• State health benefits high risk pool coverage
• Coverage under the high risk pool
• Coverage for small businesses and their employees (small group market)