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Paul Zimmerman
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Showing 89 posts in Health Care.

Health Care
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Health Care Company to Pay $514 Million to Settle Kickback Allegations

Tenet Healthcare Corp. has agreed to pay states and the federal government $514 million to settle allegations that its hospitals in Georgia and South Carolina paid kickbacks for obstetric referrals. This massive settlement illustrates the importance of health care services companies (i.e. hospitals) not only implementing a detailed compliance program but also valuing complete transparency with regard to business relationships, particularly when it comes to maintaining open communication with counsel. (Read More)

Health Care
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Physician Alert: CA Balance Billing Legislation Signed Into Law

California Governor Jerry Brown has signed into law a bill that is meant to address the issue of balance billing patients when they receive non-emergency medical services from an out-of-network physician at an in-network facility. The bill, AB 72, has been on a fast track through the California legislature despite criticism from some segments of the medical provider community. Providers should be aware of this legislation, as it could significantly impact your business. (Read More)

Health Care
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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)

Health Care
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On the Clock: Physician’s Voluntary Engagement in Insurer's Internal Appeals Process Does Not Toll Statute of Limitations

An insurer’s optional appeals process does not toll the statute of limitations following unequivocal written denial of a claim. In Dev v. Blue Shield of California, a California appeals court held that the two-year statute of limitations applicable to claims for quantum meruit began to run when a health care provider received the “Explanation of Benefits” (EOBs), which constituted an unequivocal denial of payment. Out-of-network providers often appeal denied claims through an insurer’s internal appeals process. However, as laid out in the Dev decision, such appeals (and related correspondence) do not delay or otherwise suspend the statute of limitations – meaning that non-contracted physicians must be diligent in exploring and preserving their legal claims for fear of being time-barred at the conclusion of the optional appeals process. (Read More)

Health Care
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Drug Treatment Centers Must Walk a Fine Line With Respect to Marketing

A recent New York Times article entitled “How Staten Island’s Drug Problem Made It a Target for Poaching Patients,” details how recruiters for treatment centers as near as Long Island and upstate New York, and as far away as Arizona, California and Florida are soliciting recovering addicts from addiction treatment centers on Staten Island to leave and go to other centers. Recruiters allegedly find addicts, or in some cases even call patients while they are receiving treatment from other centers, and offer them money to seek treatment at a different facility. They also routinely pay for these individuals to travel to a new treatment center, where presumably they are enrolled and the marketer is paid a fee. This story brings to national attention an issue that has been building within the behavioral health community for years. (Read More)

Health Care
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SoCal Sober Living Homes Face an Array of Regulatory and Zoning Obstacles

The subject of residential sober living homes and other treatment centers located in residential neighborhoods continues to attract substantial media attention in Southern California. The topic has become a lightning rod within many Southern California coastal communities. Arguments over residential treatment centers have recently evolved into litigation as the issue continues to spur local regulatory challenges and incite great passion. The effect that these cases may ultimately have on state law and city zoning codes remains in flux, all while the state considers various proposed bills on the topic, including AB 2255 and AB 2403. For owners and providers in the sober living and residential treatment space, the time is now to ensure strict compliance with applicable licensing requirements and zoning laws. To play fast and loose with local and state regulations is to invite dire consequences. (Read More)

Health Care
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Ninth Circuit: Manipulation of Risk Adjustment Data Subjects Insurers to False Claims Act Liability

The U.S. Court of Appeals for the Ninth Circuit has revived a whistleblower suit against Aetna, UnitedHealthcare and WellPoint for allegedly submitting false data for Medicare Advantage payments. Some of the nation’s largest health insurers must face a False Claims Act (FCA) suit accusing them of turning a blind eye to improper diagnoses. The unanimous Ninth Circuit opinion reversed a lower court decision to dismiss the suit. (Read More)

Health Care
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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)

Health Care
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Criminal Charges Brought in $1 Billion Alleged Medicare Fraud Scheme

If the June 2016 nationwide Medicare fraud takedown was not a sufficient indicator, today’s announcement that the U.S. Department of Justice (DOJ) has filed criminal charges against three Florida individuals alleging more than $1 billion in health care fraud, should make very clear that the federal government is cracking down on Medicare schemes.

The owner of more than 30 Miami-area skilled nursing and assisted living facilities, a hospital administrator and a physician’s assistant were charged with conspiracy, obstruction, money laundering and health care fraud involving numerous Miami-based health care providers. (Read More)

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New Federal Proposal May Make Health-Related Travel Insurance an Excepted Benefit Under ACA

For companies selling travel insurance products, there is major news out of Washington D.C. The Obama administration is seeking to curb short-term, limited duration health policies, which includes insurance products now frequently sold within the travel insurance industry. However, the proposed new rule addresses travel insurance head-on, as it makes very clear that travel insurance products with limited health coverage are excepted benefits under the Affordable Care Act (ACA). (Read More)