Managed Care Legal Update. By: Doug Wolfe (786)

Transcription

1 Managed Care Legal Update By: Doug Wolfe (786)

2 About US Wolfe Pincavage, LLP is a boutique law firm based out of Miami, Florida that handles healthcare matters, complex business disputes and insurance cases. Our dedicated healthcare team focuses on: Complex healthcare business litigation. Managed care contracting and dispute counseling. Large-scale hospital and physician reimbursement litigation.

3 Road Map I. Revenue Cycle Case Law II. Anti-Trust Cases II. ACA III. Questions & Discussion

4 Part I: Revenue Cycle Case Law

5 Reimbursement Rates Why we look to case law. Fla. Stat requires payment of lesser of: (a) The provider s charges; (b) The usual and customary provider charges for similar services in the community where the services were provided; or (c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days of the submittal of the claim extended to EPO & PPO in 2016

6 Reimbursement Rates Baker County Med. Servs. v. Aetna Health Mgmt., LLC (2010) Seminal Florida case on UCR. UCR = fair market value not billed charges. Fair market value is what a willing buyer would pay and a willing seller would accept in an arms length transaction. Medicare and Medicaid are not arms length transactions.

7 Reimbursement Rates Dennis v. PHC-Martinsville, Inc. t/a Memorial Hospital of Martinsville & Henry County (2016) Non-Par ER Claim Billed Charges $111, Insurance paid $27, Hospital accepts 25% of charges from self-pay. Medicare pays $20K Value of services = uninsured self pay rates Financial responsibility agreement unenforceable Your money or your life is a coercive proposition, whether you have a single dollar in your pocket or $500.

8 Reimbursement Rates Children s Hospital Central California v. Blue Cross of California (2014). Verdict in favor of hospital for billed charges over turned. Court should allow evidence of Gould Factors: (i) the provider's training, qualifications, and length of time in practice; (ii) the nature of the services provided; (iii) the fees usually charged by the provider; (iv) prevailing provider rates charged in the general geographic area in which the services were rendered; (v) other aspects of the economics of the medical provider's practice that are relevant; and (vi) any unusual circumstances in the case

9 Patient Responsibility Aetna v. Humble Surgical Hosp. (2016) $41.4 million verdict in favor of Aetna. Hospital filthy up to elbows from lies and corrupt bargains Waived patient responsibility and paid kickbacks to referring physicians. Conn. Gen. Life. Ins. Co. v. Humble Surgical Hosp. (2016) CIGNA fee forgiving defense rejected. Hospital entitled to recover $13 million.

10 ERISA Employee Retirement Income Security Act is Federal law and regulatory framework that governs employment benefits. Pre-Empts State Law Claims Heightened burden of proof for claims Typical Defenses: Failed to exhaust administrative remedies. Failed to quote or attached benefit plan. Failed to identify accounts and basis for coverage.

11 ERISA/Assignment of Benefits BioHealth Med. Lab., Inc. v. Conn. Gen. Life Ins. Co. (2016) Provider suit dismissed for inadequate assignment of benefits AOB only applied to insurer not self funded plan. The core focus of the Assignment is on the assignee's ability to recover benefits "owed under any policy of insurance" and the pursuit of any rights to collect from the insurance company if for any reason the "insurance company fails to make payments due." The Laboratories' argument that the right to collect benefits stemming from a "collateral source" necessarily implicates self-funded plans is belied by the Assignment's express language.

12 ERISA/Assignment of Benefits Gables Ins. Recovery, Inc. v. UPS (2017) Collection agency ordered to pay $16K in attorneys fees for filing suit when it was advised the benefit plan contained an anti-assignment provision.

13 Part II: Anti-Trust Cases

14 Anti-Trust Cases U.S. v. Aetna (2017) Federal judge blocked Aetna/Humana merger. Proposed merger is likely to substantially lessen competition in the sale of individual Medicare Advantage plans in 364 counties and in the commercial insurance on the public exchanges in three counties in Florida. Aetna withdrew from exchange market in a number of states to improve its litigation position. Aetna may owe $1 billion break up fee to Humana.

15 Anti-Trust Cases U.S. v. Anthem Expected to be blocked as early as this week. Cigna looking to recover $1.85 billion break-up fee.

16 Anti-Trust Cases U.S. v. Advocate/North Shore (2016) Merger between Advocate and North Shore Hospital Systems in Chicago Blocked. Primary issue was definition of North Suburban market. Advocate claims merger will lower cost. FTC claims merger will create leverage for new system to command higher prices from insurance.

17 Anti-Trust Cases BCBS Anti-Trust Class Action Case Pending in Northern District of Alabama Multi-District Litigation brought against all the Blues Challenges to BCBS services areas and BlueCard program. Bellwether trial expected later this year.

18 Part III: ACA

19 ACA Tom Price Plan Tax credits for premium. Expansion of HSA. 18 months continuous coverage to avoid denial for preexisting conditions Limit deductions for insurance offered by employers. Federal money to states for high risk pools. Block grants for Medicaid. Roll back of Medicaid expansion. Sale of insurance across state lines. Eliminate essential health benefits. Not a fan of bundled payments.

20 ACA Ryan Ideas Medical malpractice reform No policy cancelation absent fraud. No lifetime caps. Insurance across state lines. No funding for abortion. Allows employers to provide financial incentives for healthier lifestyles. Expansion of HSAs to pay premiums. Block grant Medicaid. Expand Medicare advantage. Continue value based payment models.

21 ACA Susan Collins/Bill Cassidy Proposal States Choose: 1 Keep ACA 2 Develop a new market based system with federal funding. Tax credits to support premiums. Requires standard HDHP with network adequacy. 18 months continuous coverage needed to avoid medical underwriting. Limit OON ER charges to 85% UCR as set by state department of insurance. Providers must post prices for services in a manner that makes it easy for consumers to compare process charged by different providers. 3 Develop alternative health insurance system without federal funding.

22 Doug Wolfe