health insurance – Duane Morris Health Law

August 8, 2024 by Seth A. Goldberg

Health Insurance Reimbursement Price-Fixing MDL Formed

I recently reported that Multiplan and certain insurers in its network were accused of being a “cartel” that has agreed to underprice out-of-network reimbursement paid to providers in the Multiplan network in violation of federal antitrust laws. in the matter styled Live Well Chiropractic PLLC, et al. v. Multiplan, Inc., et al., (D. IL Civ. No. 1:24-cv–3680). That antitrust action, along with six other similar actions, were consolidated for pre-trial proceedings by the Joint Panel on Multi-District Litigation (JPML) into a multi-district litigation in the Northern District of Illinois before The Honorable Matthew Kennelly. See JPML Transfer Order.

While defendants in certain of the actions sought transfer of the MDL to the Northern District of California, and others hoped transfer would not occur until a motion to dismiss in an action in New York District Ct. was heard, the JPML ruled that ” the Northern District of Illinois is an appropriate transferee district for this litigation” because “six actions are pending in that district, which has the support of both some plaintiffs and all defendants. Two defendants are headquartered in Illinois, and several others are located nearby. Judge Matthew F. Kennelly is well-versed in the nuances of complex and multidistrict litigation, and we are confident he will steer this litigation on a prudent course.”

The price-fixing claims assert that Multiplan uses an algorithm that Multiplan claims “reprices” OON services based on historical reimbursements to providers providing the same services, and then “overrides” that amount to pay lower rates agreed upon by Multiplan and the insurers. The insurers, who are allegedly horizontal competitors, are claimed to provide competitively sensitive information about their reimbursement that they would not provide in a competitive market, and many serve on a Multiplan advisory board that meets in furtherance of the conspiracy to fix prices.

May 2, 2019April 27, 2023 by Emmy S. van den Ban

Recent Federal Legislative Activity to Address Surprise Billing

States increasingly pass laws to protect patients from surprise billing, varying widely in scoop. Surprise bills occur when a patient is treated by an out-of-network provider and receives a bill from the provider for the difference between the payment made by the health plan and the patient’s cost-sharing amount. Typical scenarios are when a patient accesses emergency services outside the health plan’s network or receives services at an in-network hospital from an out-of-network physician (e.g., anesthesiologist, radiologist, pathologist). Despite state legislative activity, state protections are limited by the Employee Retirement Income Security Act of 1974 and do not apply to self-funded employee welfare benefit plans. According to the Kaiser Family Foundation, approximately 60 percent of workers get coverage through a self-funded health plan. Because these state-level protections vary widely in scope and do not apply to patients in self-funded health plans, federal legislation may provide an opportunity to more comprehensively address surprise billing. Continue reading “Recent Federal Legislative Activity to Address Surprise Billing”

April 30, 2015May 1, 2015 by Seth A. Goldberg

SCOTUS Limits Claims Brought by Healthcare Providers’ for Denied Medicaid Reimbursement

In a recent 5-4 decision by the U.S. Supreme Court, Armstrong v. Exceptional Child Center, Inc., Slip. Op., 575 U.S. ____ (March 31, 2015), Justice Scalia, writing for the majority, took aim at health care providers seeking to enforce Medicaid rate-setting provisions against a state that refused to incorporate those provisions in the state’s Medicaid plan, and instead reimbursed providers for Medicaid services at lower rates.

In Armstrong, the plaintiffs, providers of habilitation services under Idaho’s Medicaid plan sought an injunction to prevent Idaho’s State Department of Health from violating Section 30(A) of Medicaid, 42 U.S.C. § 1396(a)(30)(A), which requires a state to “assure that payments are consistent with efficiency, economy, and quality of care,” while “safeguard[ing] against unnecessary utilization of. . . care and services.” The Court reversed the Ninth Circuit’s decision that the Supremacy Clause gave the providers an implied right of action to seek an injunction requiring Idaho to comply with Section 30(a). Continue reading “SCOTUS Limits Claims Brought by Healthcare Providers’ for Denied Medicaid Reimbursement”

December 19, 2011August 19, 2014 by Patricia S. Hofstra

Proposed Physician Payment Disclosure Rule Published

The Centers for Medicare and Medicaid Services (“CMS”) released its proposed rule regarding the required reporting of device, biologics and pharmaceutical manufacturer payments to physicians on December 14, 2011. The proposed rule includes templates for physicians and manufacturers to use when logging payments and gifts.

Continue reading “Proposed Physician Payment Disclosure Rule Published”

November 30, 2011September 10, 2014 by Duane Morris

HHS Awards Planning Grants to States to Establish Insurance Exchanges

The Department of Health & Human Services (“HHS”) Secretary Kathleen Sebelius recently announced the distribution of $220 million to states for the creation of private health-insurance exchanges. Alabama, Arizona, Delaware, Hawaii, Idaho, Iowa, Maine, Michigan, Nebraska, New Mexico, Rhode Island, Tennessee and Vermont were the state recipients in this latest funding effort, and Rhode Island is the first state to receive a Level Two grant geared towards states in more advanced planning stages. State health insurance exchanges are expected to start operating in 2014. Currently only 13 states have enacted legislation to establish insurance exchanges; though 49 states have received planning grants so far.

Read HHS’ full press release here.