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»  Posts By   May 2018 

Why Out-of-Network Providers Need a Limited Power of Attorney from Patients After Recent Appellate Court Decision

Many OON providers utilize assignment of benefit forms so that a provider can be paid by an insurance company directly or the provider can dispute nonpayment or under payment instead of this action being taken by the patient. However, last week in American Orthopedic & Sports Medicine, v. Independence Blue Cross Blue Shield; Horizon Blue Cross Blue Shield of New Jersey, the 3rd Circuit Court of Appeals determined that anti-assignment...

PHARMACY ALERT: Express Scripts Demands “Mail Order Attestation” Limiting Mail Order and Delivery Services

Recently, Express Scripts (ESI) has begun demanding independent retail pharmacies sign a "Mail Order Attestation," limiting the pharmacy's ability to provide mail order and delivery services to ESI members to only 10% of all claims submitted to ESI. Per ESI's correspondence, a failure to return an executed "Mail Order Attestation" in a timely manner will result in the pharmacy's termination from ESI’s network. Pharmacies have rights to challenge this unlawful...

Surgical Practice Licensure: Department of Health Training Sessions

On January 16, 2018, New Jersey Governor Chris Christie signed A-4995/S-287 into law, requiring all registered surgical practices to become licensed by the New Jersey Department of Health (DOH) as Ambulatory Surgical Facilities (ASCs). The passage of the law created a number of new opportunities for such facilities upon becoming licensed, including the ability to take on non-physician capital partners and allow non-owners to utilize the facility. Additionally, the law...

How Medical Practices Should Respond to an Audit or Request for Documents

Payors audits are at an all-time high. Private payors employ third-party analytical firms to constantly run reports to find "outliers" and practices with coding aberrancies. While some audits are routine and pursuant to provider agreements, others could expose practices civilly and criminally. In order to properly triage an audit and determine how to address it, it is recommended that every practice engage in "preventative medicine": Practice Policies and Procedures Every...

Pharmaceutical Manufacturers, Wholesalers, and Distributors: Prepare for High Stakes Opioid Litigation

Earlier this year, Attorney General Jeff Sessions announced the creation of a task force to pursue the makers and distributors of prescription opioids and his intention for the Justice Department to play a substantial role in supporting plaintiffs throughout the country in prescription opioids-based lawsuits. In addition to the Justice Department's vocal support of such legal action, numerous lawsuits, including class action lawsuits, have already been filed throughout the United...