Insights on Managed Care, Payer Disputes & Reimbursement

On February 6, 2023, health care providers scored a second significant victory when a federal court in Texas again vacated portions of the Biden Administration’s rules governing the arbitration procedures to resolve surprise billing disputes under the federal No Surprises Act (NSA).

In late September 2022, health care providers in Texas sued the Departments of Treasury, Labor, and Health and Human Services (collectively, the Departments) over a recently issued final rule implementing the federal No Surprises Act (the NSA).

Earlier this month, the US District Court for the Western District of Washington certified a class of individuals who were denied gender-affirming care by a third-party administrator, Blue Cross Blue Shield of Illinois (BCBSIL).

Health Care Partner Stephanie Trunk will present twice at the Informa Medicaid Drug Rebate Program Summit on October 12-14.

In Advisory Opinion 22-17, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) concluded that a proposed restructuring of a loan and other contractual relationships between a health system and a federally qualified health center (FQHC) “look-alike” clinic.

On August 19, 2022, the US Departments of Health and Human Services, Labor, and Treasury, as well as the Office of Personnel Management, released a highly-anticipated final rule clarifying the procedures and considerations for resolving disputes related to surprise medical bills.

On June 21, 2022, the Supreme Court concluded, in Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc., No. 20-1641, 2022 WL 2203328 (U.S. June 21, 2022), that the terms of a benefit plan limiting reimbursement for dialysis treatment did not violate the MSP Act.

ArentFox Schiff is pleased to announce that four attorneys have been named to BTI’s Client Service All-Stars 2022 for delivering superior client service: Partners Paula Morency, Caroline Turner English, Ann MacDonald, and Matthew Prewitt.

The Ninth Circuit Court of Appeals recently reversed the Northern District of California’s landmark decision against UnitedHealth Group Inc.’s behavioral health unit, United Behavioral Health (“UBH”), under which UBH had been ordered to reprocess tens of thousands of behavioral health claims.

The US Supreme Court heard oral argument to decide a circuit split and determine what ERISA requires of ERISA-governed pension plan fiduciaries with respect to investment fees and recordkeeping. A decision is expected in the first half of 2022.

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.

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.