Uncategorized

The “Other” Supreme Court Decision

While much attention has focused on recent Supreme Court decisions involving reproductive care rights and presidential immunity, a less-noticed case has potential implications for the health care industry. In the case of Securities and Exchange Commission v. Jarkesy, the Supreme Court ruled last week that the SEC’s use of administrative proceedings to levy a fine against a hedge fund manager for misleading investors deprived that manager of the right to a court trial. While the immediate ruling addresses only the SEC case, the underlying rationale has implications across the federal government – including health care agencies. Currently, the Department of [...]

joe2024-07-03T16:18:15+00:00July 5, 2024|Uncategorized|

The Times Looks at PBMs

The New York Times this week began an in-depth look at pharmacy benefit managers: the companies that administer the prescription drug benefits of more than 200 million Americans. As the Times notes, only three companies dominate the market, and its report examines when, how, and if PBMs save money for insurers and consumers; how they charge for prescription drugs; how they influence consumer access to prescription drugs – and the timeliness of that access; the effect they are having on independent pharmacies; how they make money; the influence they have on the price of prescription drugs; and more. Learn more [...]

joe2024-06-25T19:58:47+00:00June 26, 2024|Uncategorized|

Federal Health Policy Update for March 21

The following is the latest health policy news from the federal government for March 15-21. Some of the language used below is taken directly from government documents. The White House The White House has announced new actions to advance women’s health research and innovation and issued an executive order in support of that objective. The order directs executive branch agencies to integrate women’s health across the federal research portfolio; prioritize investments in women’s health research; pursue new research on women’s midlife health; and assess unmet needs to support women’s health research. Learn more from this White House fact sheet, which [...]

Providers Faring Well in Surprisingly Busy Dispute Resolution Process

Health care providers are winning more than three-quarters of all payment disputes being brought through an unexpectedly active federal Independent Dispute Resolution process. The process, created under the 2020 No Surprises Act to settle payment disagreements between providers and payers and to spare consumers surprise medical bills – especially for receiving emergency care from providers outside of their insurer’s network. 2023 saw 13 times more disputes during the first half of 2023 – nearly 300,000 cases in all – than federal officials anticipated. With more than 20 percent of the disputes submitted for resolution rejected as ineligible for the process, [...]

joe2024-02-20T21:23:48+00:00February 21, 2024|Uncategorized|

No Surprises Act Implementation Yields Mixed Results

Is the No Surprises Act working? Is it protecting patients from surprise medical bills? Are providers and insurers happy? The Washington Post reports mixed results. On one hand, millions of people have been protected from surprise medical bills. But on the other hand… Experts thought that once the terms of the program were understood there would be only about 22,000 cases sent to arbitration – the law’s Independent Dispute Resolution process – in 2022. Instead, nearly 500,000 cases went that route, with nearly half of the requests for arbitration coming from physician staffing companies owned by private equity firms. At [...]

joe2024-02-14T16:33:47+00:00February 14, 2024|Uncategorized|

States Not Depending on Federal Action on Prior Authorization

Unwilling to leave the challenge of addressing the troubling prior authorization practices of many health insurers, officials in some states are trying to take matters into their own hands. Last year, lawmakers in 29 states considered 90 different bills to impose varying prior authorization requirements on health insurers serving their constituents. Among the changes these proposals seek: shorter response times for requests for authorization and mandatory public reporting of insurers’ prior authorization activity. In addition, last year five states required insurers to engage in a practice known as gold carding: waiving prior authorization for requested items and services for individual [...]

joe2024-02-13T16:56:53+00:00February 14, 2024|Uncategorized|

Lack of Instructors Impedes Fixing Nurse Shortage

The current shortage of nurses across the U.S. can be traced in part to the lack of training opportunities for aspiring nurses and not to a lack of people seeking to pursue nursing as a career. Last year U.S. nursing programs rejected nearly 80,000 qualified applicants because they did not have the capacity train them. Driving this problem are three major challenges. First is the lack of nursing school faculty: nearly 2000 full-time faculty positions remain unfilled, and many part-time positions as well, a problem caused by low salaries; working nurses often earn much more than nursing instructors. Another complication: [...]

admin2023-10-11T13:00:09+00:00October 11, 2023|Uncategorized|

CMS Warns States About Medicaid Renewals

Some states are falling short in their efforts to process Medicaid renewal applications and are inappropriately finding too many people ineligible to continue participating in the program, the Centers of Medicare & Medicaid Services has written in a letter it sent to all 50 states. In this letter, CMS wrote that As the Centers for Medicare & Medicaid Services (CMS) has worked with states on the return to regular eligibility operations following the end of the Medicaid continuous enrollment condition, we have identified issues where states are out of compliance with renewal requirements. CMS has worked with those states individually [...]

admin2023-09-05T06:00:57+00:00September 5, 2023|Uncategorized|

No Surprises Act’s Dispute Resolution Suspended

When a federal court in Texas rejected an increase in the fee for providers to initiate payment challenges under the No Surprises Act’s Independent Dispute Resolution process, the Centers for Medicare & Medicaid Services quickly suspended use of that process while it reviewed the court ruling – suspended both the adjudication of current complaints and the filing of new ones. Almost as quickly, CMS announced that it would reduce the fee required to initiate payment disputes between providers and payers under the 2020 law that sought to prevent surprise medical bills from $350 to $50 – but it did not [...]

admin2023-08-18T06:00:20+00:00August 18, 2023|Uncategorized|

No Surprises Act Arbitration Decisions Resume

After revising its guidelines on how certain medical fee disputes should be resolved, the Centers for Medicare & Medicaid Services has directed the Independent Dispute Resolution entities responsible for arbitrating fee disputes between payers and providers to resume making and issuing their decisions. After a February ruling in federal court that aspects of CMS’s implementation of the 2020 No Surprises Act contradicted the language of the act itself and unfairly favored payers over providers, CMS ordered a moratorium on new arbitration decisions for disputes filed on or after October 25, 2022 while it reviewed and revised its guidance on how [...]

admin2023-03-22T13:00:58+00:00March 22, 2023|Uncategorized|