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Lauren R. Nunez is a counsel in Crowell & Moring’s Washington, D.C. office where she is a member of the firm’s Health Care Group. Her practice covers a wide range of litigation and counseling engagements, including representing leading managed care organizations, health benefit plans, health care providers, government contractors, and various other corporate commercial litigants. Lauren litigates complex matters in federal, state, and arbitral forums, with a particular focus on commercial health care disputes, class actions, civil antitrust, and False Claims Act suits. Lauren’s antitrust experience includes mergers and acquisitions and civil antitrust cases. She has represented clients in investigations before the Department of Justice, the Federal Trade Commission, the Department of Labor, and various state enforcement agencies.

On November 13, 2020, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule, demonstrating long-awaited efforts to streamline the regulatory framework governing the Medicaid and Children’s Health Insurance Program (“CHIP”) managed care programs.

According to CMS, the purpose of the final rule is to relax certain administrative burdens imposed by the Medicaid managed care rule promulgated by the Obama Administration in 2016. The 2016 rule (the “Mega Reg”), reflecting efforts to modernize the Medicaid and CHIP managed care programs and frustrate widespread fraud and abuse, was the first update to Medicaid managed care regulations in more than a decade.  The following blog post presents a brief summary of the final rule’s key changes.Continue Reading 2020 Medicaid Managed Care Rule Summary

CMS approved requests from five additional states to launch reinsurance programs under Section 1332 state innovation waivers in order to help alleviate high premiums in the individual health insurance markets. Colorado, Delaware, Montana, North Dakota, and Rhode Island are embracing reinsurance as a way to help insurers cover the cost of the largest claims they face. They join Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin, which have existing reinsurance programs. The positive results in these seven states are significant: a 17% drop in premiums on average in the first year of operation.

Reinsurance was a key feature of the ACA to help stabilize premiums in the individual market for 2014 – 2016, the first three years of the marketplaces. The marketplaces were new, and insurers faced much uncertainty in covering previously uninsured and under insured individuals. The ACA offered a partial safeguard against high, unpredictable medical expenses under Section 1341’s transitional reinsurance program. Estimates place the average reduction in premiums by the federal reinsurance program by as much as 14%. Based on the assumption that insurers would gain a better understanding of their members’ health status as time passed (and thus could price their products with greater accuracy), the ACA’s reinsurance program was temporary. But in 2017 premiums increased more sharply than they had in previous years, in part due to the loss of reinsurance.Continue Reading Increased State Innovation Aimed at Stabilizing ACA Marketplaces

On February 9, 2016, the D.C. Circuit, in American Hospital Association v. Burwell, No. 1:14-cv-00851 , held that a district court has jurisdiction to compel the Department of Health & Human Services (“HHS”) to address the substantial backlog of disputed Medicare claims and to make decisions within the statutory deadlines in the face of complaints by the American Hospital Association (“AHA”) and several hospitals.  Not only did the D.C. Circuit find that the suit met the threshold requirements for mandamus jurisdiction, it also opined that the circumstances of the case and the clarity of HHS’ duty to meet statutory deadlines will “likely require” issuance of the writ if HHS has not made meaningful progress in addressing the backlog by the close of the next full appropriations cycle.

After a Medicare claim is denied, the Medicare Act provides a four-level administrative appeal process, followed by judicial review. The statute includes specific time frames for each step of the process.  At the first level, the provider presents its claim to the Medicare Administrative Contractor for “redetermination,” to take place within 60 days.  The second level involves “reconsideration” by a Qualified Independent Contractor, also to be completed within 60 days.  The third level constitutes de novo review by an administrative law judge (“ALJ”) within 90 days.  The fourth and final administrative stage involves de novo review by the Medicare Appeals Council within 90 days.  Appeals should work their way through the administrative process within about a year if all of the respective time frames are met.Continue Reading DC Circuit Breathes New Life into AHA’s Suit over Medicare Appeals Backlog