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Paul Zimmerman
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Showing 11 posts by Kelly M. Hagemann.

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Under the Microscope: Substance Abuse Patient Referrals 

Governor Brown just signed Senate Bill 1228 into law, implementing Health & Safety Code §§11831.6 and 11831.7. The move directly impacts marketing practices within the world of substance abuse treatment. (Read More)

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Federal Legislation Expected on Sober Living Homes

Sober living homes offer drug- and alcohol-free, cooperative living arrangements for people in the process of recovery from addiction. Rapid growth within the sector as well as increased media attention due to some recurring concerns expressed by frustrated communities, have led many states and municipalities to rethink their approach to substance abuse treatment and explore new modes of regulation. Now, federal legislators have said that they will intervene. (Read More)

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DOJ Seeks to Block Two Major Health Insurance Mergers

The United States Department of Justice (DOJ) is suing to block two proposed mergers between major health insurance companies, claiming that the deals violate antitrust laws and would lead to increased health care costs for patients. As noted in an earlier blog post, the merger of Aetna and Humana, as well as Anthem Inc.’s acquisition of Cigna Corp., has faced many regulatory and antitrust hurdles since being announced last year. Several key stakeholders, including California insurance Commissioner Dave Jones, have expressed concern that the aforementioned mega-deals will result in an anti-competitive insurance market. Now, the DOJ has announced that it is challenging both mergers on the grounds that they "would lead to higher health-insurance prices, reduced benefits, less innovation, and worse service for over a million Americans." (Read More)

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CA Insurance Commissioner Urges U.S. Justice Department to Block Merger of Aetna and Humana

The proposed $37 billion merger of health insurance giants Aetna and Humana has faced several regulatory and antitrust hurdles since it was announced in July 2015. Aetna’s proposed acquisition of Humana also coincides with another health insurer deal in which Anthem Inc. agreed to buy Cigna Corp. If both mergers are approved, it would reduce the number of major national health insurance companies to three: Aetna, Anthem and UnitedHealth Group Inc. Stakeholders have kept a watchful eye on California, curious as to how key insurance regulators would respond to the proposed merger. Now, California Insurance Commissioner Dave Jones has issued a finding that the Aetna and Humana merger is anti-competitive. Jones formally recommended the Department of Justice block the proposed merger of Aetna and Humana. (Read More)

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Health Net Payments Trickle in to Addiction Treatment Centers as CA Regulators Investigate Insurer

As we have previously detailed, Health Net began directing a great deal of attention toward addiction treatment providers in early 2016. The payor (which has subsequently been acquired by Centene Corp.) started aggressively monitoring and investigating claims from substance abuse treatment facilities, and then dramatically expanded its attestation requests to smaller providers. Among other things, Health Net scrutinized referral practices, the medical necessity of services, and whether providers were waiving out-of-pocket payments from patients. Providers throughout California, as well as states like Arizona, Nevada and Texas, received attestation requests regardless of whether Health Net had any specific evidence of fraud and abuse. At the same time, providers found that Health Net payments stopped completely, including payments for previously-submitted claims that pre-dated the attestation letters.  Now, while some providers are beginning to receive reimbursements from Health Net, the California Department of Insurance (CDI) has reportedly opened an inquiry into the improper withholding of payments. (Read More)

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NY Hospital to Pay $2.2 Million for Allowing TV Crew to Videotape Dying Patient

On the ABC television series “NY Med,” doctors from New York-Presbyterian Hospital (NYP) are profiled as they perform medical procedures. However, in an effort to keep it “real,” the show’s crew has landed the hospital in hot water. The Department of Health and Human Services, Office for Civil Rights (OCR) announced that it has reached a $2.2 million settlement with NYP for the “egregious disclosure” of two patients’ protected health information (PHI) to film crews and staff during the filming of “NY Med,” without first obtaining authorization from the patients. In particular, OCR found that the hospital allowed the television crew to film a dying patient and another person in significant distress, even after a medical professional urged the crew to stop. (Read More)

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Health Net Deepens Investigation of Addiction Treatment Centers

As noted in a blog posted earlier this year, addiction treatment providers have been receiving an increased number of requests from payors seeking a range of medical and billing records and other documentation concerning the provision of substance abuse treatment and related services. Several major payors have begun aggressively monitoring and investigating claims, and now Health Net has separated itself from the pack by dramatically expanding its attestation requests to smaller providers. While there are, no doubt, some bad actors in the addiction treatment community, it appears that health insurers are cracking down hard on all providers in an effort to ferret out allegedly fraudulent practices. (Read More)

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Health Net And Other Payers Ramp Up Audits Against Addiction Treatment Providers

Over the past several months, we have seen a tremendous amount of payer attention directed at addiction treatment providers. Payers are sending increasing numbers of requests seeking a range of medical records, billing records and other documentation concerning the provision of substance abuse treatment and related services, with several major payers seeming to aggressively investigate providers’ claims. Payer requests range from commonplace medical record requests, on the one hand, to requests for information about patient residency and co-payment obligations on the other, and have included requests for facility licenses, state and county certifications, and CLIA certificates. (Read more)

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Adventist to Pay $118.7 Million Settlement in Whistleblower Lawsuit

On Monday, September 21, 2015, the Department of Justice announced a settlement with Florida-based Adventist Healthcare, whereby the company will pay $118.7 million to settle a whistleblower lawsuit. $115 million, the bulk of the settlement, will go to the federal government with $3.4 million going to the state of Florida, and the rest to be divided between North Carolina, Tennessee and Texas. The genesis of the allegations stemmed from a qui tam lawsuit initiated by three former Adventist employees, who claimed that the healthcare company improperly compensated physicians in exchange for referrals, in addition to submitting miscoded claims to obtain excess payments from the federal government. These alleged violations led to potential liability for Adventist under the False Claims Act, a broad law that prohibits any person from knowingly presenting, or causing to be presented, a false claim to the government for payment or approval.  It also prohibits the retention of any overpayments that resulted from past false claims, even if those “false claims” were accidental at the time they were made.

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Court’s Interpretations of Damages under California’s Confidentiality of Medical Information Act

Without a doubt, technology has made life easier for doctors. Now, instead of toiling away in their offices late into the night, they can take medical records home with them on tablets and smartphones, giving them 24-7 access to patients’ medical information from wherever they choose to work. Unfortunately, these mobile devices increase the risk of security breaches, which is concerning both for patients, whose medical records could be stolen, and providers, who may be subject to civil penalties resulting from the theft. This is because California’s Confidentiality of Medical Information Act (CMIA) sets forth that a plaintiff is able to recover damages in an amount set by statute, as opposed to having to prove actual financial losses. (Read more)