In yet another high-profile legal action, health insurance giant, Humana, has demonstrated its appetite to go after pharmaceutical manufacturers, supporting hubs and specialty pharmacies involved in patient assistance programs.  This past week,... Read More
Blogs & Articles | Life Sciences | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | Pharmaceutical Manufacturers | Pharmacy Law | Specialty Pharmacies

The State of Texas recently enacted H.R. 3459, a law that permits prescribers to earn a “gold card” exemption from Prior Authorization (PA) requirements based on a track record of previous PA approvals from insurers (preferred provider and... Read More
Blogs & Articles | Life Sciences | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | Pharmacy Law

A Texas husband and wife dentist team recently reached an agreement with the United States Department of Justice (“DOJ”) to pay $3.1 Million to resolve allegations that they violated the False Claims Act (“FCA”) by defrauding the Texas... Read More
Blogs & Articles | Dental Practices | Healthcare | Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | White Collar Criminal Defense & Government Investigations

Providers enrolled in Medicare and/or Medicaid are aware of the myriad of rules associated with coverage for services and the submission of claims, but they are sometimes surprised to learn that neglecting to update their enrollment status and... Read More
All types of single and multi-specialty medical practice groups | Blogs & Articles | Community, Retail Pharmacies | Healthcare | Life Sciences | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | Pharmacy Law

Physician groups contracting with government-regulated health plans such as Medicare-Advantage Organizations, Medicaid Managed Care Organizations, or ACA Marketplace Individual/Small Group Issuers often enter into capitated payment models with... Read More
Blogs & Articles | Healthcare | Healthcare Law | Healthcare Litigation | Medicare and Insurance Audits | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | Recent Results | Recent Successes | Value Based Care | Value Based Care

Following the release of an April 16, 2021 HHS Office of Inspector General (“OIG”) report entitled “Medicare Advantage Compliance Audit of Diagnosis Codes that Humana, Inc. (Contract H1036) Submitted to CMS” (the “OIG Report”), headlines... Read More
All types of single and multi-specialty medical practice groups | Blogs & Articles | Healthcare | Healthcare Law | Healthcare Litigation | Medicare and Insurance Audits | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News & Press | Value Based Care

Earlier this week following a three-day bench trial, the owner of, and a licensed mental health counselor at, a Tallahassee-based counseling center, were found guilty of health care fraud conspiracy, health care fraud, and aggravated identity theft.... Read More
Blogs & Articles | Healthcare | Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News & Press | White Collar Criminal Defense & Government Investigations

The “law” applicable to drug reimbursement encompasses an array of laws across 50 states, the territories, and the federal government. These laws and regulations determine what a “Plan Sponsor” (such as an insurance plan, State Medicaid... Read More
Blogs & Articles | Community, Retail Pharmacies | Life Sciences | Maximum Allowable Cost Pricing & Appeals | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News & Press | Pharmacy Law | Plan Sponsor PBM Contract Services

One: According to Supreme Court Justice Antonin Scalia, “Administrative Law is not for sissies.” Medicare rules in general, and the appeals process, in particular, are codified in a complex body of regulations known as administrative law.... Read More
Blogs & Articles | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

The U.S. Attorney’s Office, Western District of Louisiana, recently announced that the owner and operator of the Monroe-based Specialty Drug Testing, LLC (“Specialty”) was indicted by a Federal grand jury for violating the Federal... Read More
Healthcare | Healthcare Law | Hospitals and Healthcare Systems | Laboratories | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals