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C&M Health Law

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Category Archives: Litigation

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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

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

Mount Sinai Health System to Pay $2.95 Million in 60-Day Overpayment FCA Settlement

Posted in Fraud, Waste & Abuse, Health Care Reform & ACA, Litigation
On August 24, 2016, Judge Edgardo Ramos of the Southern District of New York approved a settlement in which Mount Sinai Health System (Mount Sinai) will pay $2.95 million to New York and the federal government to resolve allegations that it violated the False Claims Act (FCA) by withholding Medicare and Medicaid overpayments in contravention… Continue Reading

DC Circuit Breathes New Life into AHA’s Suit over Medicare Appeals Backlog

Posted in Litigation, Medicare
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… Continue Reading

Crowell & Moring’s 2016 Litigation & Regulatory Forecasts: What Corporate Counsel Need to Know for the Coming Year

Posted in Administrative Law, Antitrust, EHR, Health Care Reform & ACA, Health IT, Litigation, Medicaid, Medicare, Tax
Featured Industry: Health Care Spotlight on Best Practices, Litigation, Antitrust, and Tax for Health Care Companies Crowell & Moring LLP is pleased to release its “2016 Litigation & Regulatory Forecasts: What Corporate Counsel Need to Know for the Coming Year.” The reports examine the trends and developments that will impact health care companies and other… 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

New California Court of Appeal Decision May Impose Premium Taxes on California Health Plans

Posted in Litigation
Since their inception, California health care service plans have been considered not to be insurers for purposes of the State’s 2.35 percent gross premium tax. Under a controversial ruling issued by the Court of Appeal, this could change. On September 25, the Court of Appeal held that a suit alleging that California’s Blue Shield and… Continue Reading

DOJ’s Memo on Individual Accountability Tears at the Corporate Veil

Posted in Fraud, Waste & Abuse, Litigation
The Department of Justice (DOJ) has further focused its sights on individual executives as responsible parties for corporate misconduct.  On September 9, 2015, Deputy Attorney General Sally Quillian Yates issued a strongly worded seven-page memorandum to all U.S. Attorneys and the Assistant Attorneys General of DOJ’s various divisions nationwide titled “Individual Accountability for Corporate Wrongdoing”… Continue Reading

S.D.N.Y. Provides First Judicial Guidance on Identifying Overpayments and Effect on FCA Liability

Posted in Fraud, Waste & Abuse, Health Care Reform & ACA, Litigation
On August 3, 2015, in Kane v. Healthfirst, Inc., No. 1:11-cv-02325-ER (S.D.N.Y. Aug. 3, 2015), Judge Edgardo Ramos of the Southern District of New York decided an issue of first impression under the False Claims Act (FCA) requirement to return identified overpayments from Medicare and Medicaid within sixty (60) days. In denying the defendants’ motion… 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 Corporate Counsel Need to Know in 2015 – Litigation and Regulatory Forecasts from Crowell & Moring

Posted in ERISA, Health Care Reform & ACA, HIPAA & Privacy, Litigation, Medicaid, Medical Loss Ratios, Medicare
Crowell & Moring’s 2015 Litigation and Regulatory Forecasts provide an in-depth look at the trends in the courts and in the regulatory agencies, both inside the Beltway and beyond, that will impact business in the coming year. The Litigation Forecast examines the latest litigation developments facing companies in areas ranging from health care and antitrust… Continue Reading

Settlement in FCA Qui Tam Case Disposes of Claims Alleging Falsely Certified Compliance with Medicare Advantage Rating Instructions

Posted in Fraud, Waste & Abuse, Litigation, Medicare
 After a protracted battle, Kaiser Foundation Health Plan, Inc. (Kaiser) recently settled a False Claims Act (FCA) qui tam case alleging that it falsely certified compliance with Medicare Advantage (MA) bidding instructions that relator claimed resulted in billions of dollars in damages to the United States. Crowell & Moring represented Kaiser in the litigation. Kaiser’s… Continue Reading

HOOPS 2014: Legal Flashpoints and Developments

Posted in Antitrust, Fraud, Waste & Abuse, HIPAA & Privacy, Litigation, Medicare, Mental Health Parity
This year Crowell & Moring’s Healthcare Ounce of Prevention Seminar, (HOOPS), will focus on important legal and regulatory developments and their impact on the healthcare industry. Join us on October 27th and October 28th in Washington, DC as our healthcare attorneys and outside speakers share their perspectives on the latest developments in areas of interest… 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

United States Appellate Courts Issue Dueling Opinions on Availability of Tax Credits in Federally Facilitated Exchanges

Posted in Exchanges, Health Care Reform & ACA, Litigation
The Obama Administration received mixed messages yesterday when two federal appellate courts issued contradictory rulings on whether tax credits are available for individuals to purchase health insurance from federally facilitated Exchanges operating in 36 states. The U.S. Court of Appeals for the D.C. Circuit delivered a stiff rebuke to the Obama Administration, issuing a 2-1… Continue Reading

Sixth Circuit Rules Provider Has Private Right of Action against NGHP Under Medicare Secondary Payer Act without Requiring Proof of Denial Based on Medicare Eligibility

Posted in Litigation, Medicare
The Sixth Circuit held in Michigan Spine and Brain Surgeons, PLLC v. State Farm Mutual Automobile Insurance Company (No. 13-2430) that a health care provider can bring an action under the Medicare Secondary Payer (MSP) Act’s private cause of action provision against a non-group health plan (NGHP) without first demonstrating that the NGHP denied coverage… Continue Reading

Hot off the Presses! Latest Edition of Managed Care Lawsuit Watch

Posted in Federal Employee Health Benefits Program (FEHB), Litigation, Managed Care Lawsuit Watch, Medicare
Managed Care Lawsuit Watch is Crowell & Moring’s summary of key litigation affecting managed care. The latest issue covers a broad range of lawsuits, including: Medicare’s preemption of state common law negligence claims; arbitration clauses in provider agreements; the right of a Medicare Advantage plan to assert a lien on a deceased beneficiary’s negligence settlement;… 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

Landmark False Claims Act Judgment: What Hospitals and Healthcare Providers Should Know

Posted in Fraud, Waste & Abuse, Litigation
On October 2, 2013, the federal district court in Columbia, South Carolina imposed a landmark $237 million judgment in a much-discussed False Claims Act case which was predicated on violations of the Physician Self-Referral (Stark) Law, U.S. ex rel. Drakeford v. Tuomey Healthcare System, Inc.1 The case was originally filed as a qui tam case… Continue Reading

CMS Issues Guidance on Internal Revenue Ruling 2013-17 re Same-Sex Marriage

Posted in Exchanges, Health Care Reform & ACA, Litigation, Medicaid
In the wake of United States v. Windsor, the case in which the Supreme Court held the Defense of Marriage’s (DOMA) prohibition on federal recognition of same-sex marriages unconstitutional, the Internal Revenue Service issued Internal Revenue Ruling 2013-17. The Ruling held that same-sex individuals who were married under state law would be considered married for… Continue Reading

Fourth Circuit Upholds Constitutionality of Both Individual and Employer Mandate

Posted in Exchanges, Health Care Reform & ACA, Litigation
On July 11, 2013, the U.S. Court of Appeals for the Fourth Circuit, reconsidering a case in light of National Federal of Independent Business v. Sebelius, 132 S. Ct. 2566 (2012) (hereinafter NFIB), upheld the constitutionality of both the individual mandate and employer mandate of the Patient Protection and Affordable Care Act (ACA). In Liberty University… Continue Reading