C&M Health Law

C&M Health Law

Analysis, commentary, and the latest developments in health care law and policy

Harsh P. Parikh

Harsh P. Parikh

Harsh P. Parikh is an associate in Crowell & Moring’s Los Angeles office, where he practices in the Health Care and Litigation groups. Harsh represents individuals, businesses, institutional, and public entity clients in all facets of litigation in state and federal courts. In the Health Care Group, his practice includes representing and counseling managed care organizations and health care providers in a wide range of regulatory, transactional, and litigation matters.

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California Supreme Court Prohibits Waiver of Public Injunctive Relief in Arbitration Agreements

Posted in Litigation
A recent California Supreme Court decision has significant implications for any agreement attempting to waive a substantive statutory remedy in California. In McGill v. Citibank, the Court held that an arbitration provision that provides for a waiver of the right to seek public injunctive relief is contrary to California public policy and unenforceable.  The Court… Continue Reading

HHS Proposes New Regulations Aimed At Stabilizing the Individual Market

Posted in Exchanges, Health Care Reform & ACA
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule  to stabilize the individual and small group markets to entice issuers to continue participation in the exchanges in 2018 despite continued uncertainty surrounding repeal and replacement proposals for the Affordable Care Act (ACA). The proposed rule, published today, would make the following changes… Continue Reading

ACA Repeal and Replace Update: President Trump’s Executive Order Directs Executive Branch to Minimize the Economic Burden of the ACA

Posted in Exchanges, Health Care Reform & ACA, Medicaid, Tax
On January 20, 2017, hours after being sworn in as the 45th president of the United States, President Donald Trump issued Executive Order 13765 that aims to “minimize the unwarranted economic and regulatory burdens” of the Affordable Care Act (ACA) while its repeal is “pending.”  The one-page Executive Order declares that it is the policy… Continue Reading

$33 Million Settlement Approved For Systematic and Improper “Bundling” of Chiropractic CPT Codes

Posted in ERISA, Managed Care Lawsuit Watch
In what appears to be one of the largest class action settlement in the history of ERISA litigation in New Jersey, a federal judge approved $33 million settlement, including $11 million in attorneys’ fees, between Horizon Healthcare Services, Inc. (“Horizon”) and plaintiff chiropractors. The underlying lawsuit stemmed from allegations that Horizon made “across-the-board” denials of… Continue Reading

CMS Issues Final Rules on MACRA Quality Payment Program Implementation

Posted in Medicare
On November 2, 2016, the final rule with comment period (the “Final Rule”) implementing provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) relating to the new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) will be published in the Federal Register.  The Center for Medicare and Medicaid Services (CMS) also launched… Continue Reading

New California Law To Target Surprise Bills Impacts Payor Relationships With Non-Contracted Professionals

Posted in Exchanges, Litigation, Managed Care Lawsuit Watch
California recently enacted Assembly Bill 72 (“AB 72”) to target surprise medical bills from out-of-network professionals.  The new law applies to commercial plans licensed by the Department of Managed Health Care and the Department of Insurance.  AB 72 sets reimbursement rates for out-of-network professionals at in-network facilities at either the average contracted rate, or 125… Continue Reading

Supreme Court Recognizes FCA Exposure Based on Implied Certification Theory

Posted in Fraud, Waste & Abuse, Government Contracts
In a unanimous decision last week that impacts healthcare providers, vendors and health plans that receive Medicare and Medicaid reimbursements or contract with federal health care programs, the United States Supreme Court in Universal Health Services v. United States ex rel. Escobar held that a defendant may be liable under the implied certification theory under… Continue Reading

OIG Updates Policy on Permissive Exclusions Based On Fraud and Kickbacks

Posted in Administrative Law, Fraud, Waste & Abuse, Medicare
The Office of the Inspector General of the Department of Health and Human Services (OIG) last week replaced a 20-year old policy statement, and issued guidance on the criteria the agency will use to evaluate whether to exclude certain individuals and entities from billing or “participation in” Federal health programs under its permissive exclusion authority.… Continue Reading

CMS Suspends Automatic Reduction of Star Ratings for Plans and Sponsors Subject To Intermediate Sanction

Posted in Medicare
Last month, the Center for Medicare & Medicaid Services (CMS) issued a memorandum announcing a change pertaining to the effect of intermediate sanctions on the calculation of Star Ratings for Medicare Advantage organizations (MAOs) and Part D sponsors.  This is a significant change for plans. The Star Rating program has continued to evolve since being… Continue Reading

$9.9 Million Settlement To Resolve Allegations That Hospital System Overpaid Physicians Approved by Georgia Federal Court

Posted in Fraud, Waste & Abuse
On February 8, 2016, the United States District Court in the Southern District of Georgia approved the settlement agreement ending a whistleblower lawsuit initiated on March 9, 2011 against Memorial Health University Medical Center (“Memorial Medical Center”) and three affiliated entities in a case that highlights the Department of Justice’s (“DOJ”) vigorous scrutiny of physician… Continue Reading

Medicaid Rules for Covered Outpatient Drugs Finalized by CMS; SIPs Required To Be Modified By April 1, 2017

Posted in Health Care Reform & ACA, Medicaid
Almost four years after publishing its proposed rule, the Centers for Medicare & Medicaid Services (CMS) released its final rule on February 1, 2016, pertaining to Medicaid reimbursement for covered outpatient drugs.  The finalized regulations implement provisions of the Affordable Care Act, and revise several key aspects of Medicaid program on drug rebates, and coverage… Continue Reading

Negating Elements for Kickbacks: District Court in the Fifth Circuit Grants Defendant’s Partial Summary Judgment Motion

Posted in Uncategorized
In a December 10 decision, the United States District Court for the Southern District of Texas granted partial summary judgment in favor of a pharmaceutical company in a qui tam action – holding that the Relators’ discovery responses demonstrated that they could not prevail at trial on certain FCA claims. Among other things, Relators alleged… Continue Reading

Sequestration Extended to 2025 in Federal Budget Deal

Posted in Administrative Law, Litigation, Medicare
On November 2, President Obama signed the Bipartisan Budget Act of 2015. As an offset for near-term increases in federal spending, the new law extends by one year – to 2025 – two-percent sequestration reductions in federal spending for mandatory federal programs including Medicare.  The end result is that Medicare Advantage Organizations (MAOs) can expect… Continue Reading

Supreme Court To Take Up Implied Certification Theory of FCA Liability

Posted in Fraud, Waste & Abuse, Health Care Reform & ACA, Litigation
Last week, in a case that will have a significant impact on future False Claims Act (FCA) suits against health care entities, the Supreme Court granted certiorari in Universal Health Services, Inc. v. United States ex rel. Escobar.  By agreeing to hear the case, the Court will resolve the circuit split over the so-called “implied… Continue Reading

CMS Issues Guidance on Part D’s “Any Willing Pharmacy” Requirement

Posted in Health Care Reform & ACA, Medicare
Citing concerns about transparency and timing, on August 13, 2015, CMS issued a memorandum to clarify guidance to Medicare Part D sponsors regarding the any willing pharmacy requirement. Medicare Part D sponsors are required to contract with any pharmacy that meets the Part D sponsor’s standard terms and conditions.  CMS requires that the standard terms… Continue Reading

CMS Proposes To Modify “Two-Midnight Benchmark” To Broaden Exceptions for Part A Payments for Short Inpatient Stays

Posted in Fraud, Waste & Abuse, Medicare
On July 8, 2015, CMS issued proposed regulations that would modify the “two-midnight rule” that governs payments by Medicare Part A for short inpatient hospital stays.  The proposed changes are contained in the CY 2016 proposed regulations for the Hospital Outpatient Prospective Payment System (OPPS).  Stakeholders may submit comments on the proposal by August 31,… Continue Reading

Partners Halt Acquisition of Boston Area Hospital After Court’s Rejection of Consent Judgment

Posted in Antitrust, Litigation, Managed Care Lawsuit Watch
On February 17, 2015, the largest health care provider in Massachusetts, the non-profit Partners Healthcare System, Inc. (Partners), dropped its bid to acquire South Shore Hospital based in South Weymouth, and the Commonwealth of Massachusetts dropped its antitrust suit that had challenged the acquisition.[1] Whether state or federal regulators will permit Partners’s proposed acquisition of… Continue Reading

What Insurers Should Know About Emergency Regulations from the California Dept. of Insurance

Posted in Administrative Law
The California Department of Insurance (CDI) has issued emergency regulations governing health insurer provider networks that became effective January 30, 2015.  The new regulations, which do not modify existing standards for plans licensed under California’s Knox-Keene Act, impose several requirements on health insurers, including standards for network adequacy, timely access to care, provider directories and… Continue Reading

Ninth Circuit Rejects Challenges to Affordable Care Act’s Individual Mandate and Independent Payment Advisory Board

Posted in Health Care Reform & ACA, Litigation
On September 2, 2014, the Ninth Circuit, in the case of Coons and Novack v. Jacob L. Lew, et. al., rejected a constitutional appeal by an uninsured plaintiff and Arizona physician challenging two critical pieces of the Affordable Care Act: (1) the Independent Payment Advisory Board (IPAB), which monitors Medicare spending (referred to by its… Continue Reading

California Court of Appeal Revisits Litigation on Valuing Reasonable & Customary Charges

Posted in Litigation, Medicare
In a June 2014 opinion, the California Court of Appeals determined that reasonable & customary (R&C) charge valuations can consider actual payments accepted by a hospital for its services, not just the billed charges based on its charge master. This means that when determining the R&C values of services, California courts are required to consider… Continue Reading