OIG Releases 2017 Work Plan

On November 10, 2016, the Office of Inspector General (“the OIG”) of the U.S. Department of Health and Human Services (“DHHS”) released its 2017 Work Plan.  Published annually and updated throughout the year, the Work Plan identifies the OIG’s key areas of focus as it carries out its mission of protecting the integrity of programs within DHHS.  The OIG is charged with ensuring the integrity of more than 100 programs administered by DHHS, including those within the Centers for Medicare and Medicaid Services, Center for Disease Control and Prevention, the Food and Drug Administration, and the National Institute of Health. The OIG Work Plan summarizes the OIG’s current activities – comprised of both new and revised activities — along with information regarding previously identified activities that have been completed, postponed, or cancelled.

The Work Plan highlights new and continuing priorities applicable to various provider types, including hospitals, nursing homes, hospices, home health, clinical laboratories, physicians and other health professionals, medical equipment suppliers and manufacturers, pharmaceutical manufacturers and other providers and suppliers.

The 2017 Work Plan is available here.

The following is a sampling of some of the new and ongoing efforts highlighted in the Work Plan:

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Amanda Hayes

Amanda Hayes

Amanda Hayes counsels clients in connection with mergers and acquisitions, divestitures and other business matters, with a particular focus on the health care industry. She regularly serves as lead counsel on acquisitions and divestitures, guiding the client through deal structuring, due diligence, drafting, negotiation and closing. In addition to health care, Ms. Hayes’ mergers and acquisition experience includes a variety of industries, such as manufacturing, retail, automotive, contract research, environmental remediation, engineering and construction supply.

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N.C. DHHS Announces Timeline for LME/MCO Mergers

In a letter dated March 17, 2016, Richard Brajer, Secretary of the North Carolina Department of Health and Human Services, announced that the Local Management Entity-Managed Care Organization (“LME/MCO”) merger process would be moving forward beginning this summer.  Currently, there are eight LME/MCOs that manage Medicaid- and State-funded mental health, intellectual and developmental disability, and substance abuse services through a federal waiver.  After the newly announced mergers, these eight LME/MCOs will be organized into four regional organizations to include: an East Regional LME/MCO (consisting of  a merger between Trillium Health Resources and Eastpointe); a North Central Regional LME/MCO (consisting of a merger between Cardinal Innovations and CenterPoint); a South Central Regional LME/MCO (consisting of a merger between Alliance Behavioral and Sandhill Center); and a Western Region LME/MCO  (consisting of a merger between Smoky Mountain Center and Partners Behavioral Health).

The Department believes these mergers will decrease the administrative burden on providers, who are currently required to follow the requirements and deal with the credentialing and billing systems of as many as eight LME/MCOs and will result in better coordination of care and scalability of services. However, providers who have previously experienced these types of transitions know that such a massive process will almost certainly have some negative short-term effects on business and clinical operations.  Providers should look to actively engage in the planning and transition process as much as possible over the coming months and keep a close eye on potential pitfalls that may arise during this process.  Parker Poe will be closely monitoring this processing going forward as well and are happy to work with providers to best manage these uncertain times in the life of their business.

Robb Leandro

Robb Leandro

Robb Leandro assists his client with a broad range of legal issues relating to health care, administrative law and public policy. His legal practice focuses on helping health care providers navigate the minefield of regulations that they face in their practices. Robb routinely assists his clients with issues including Medicaid and Medicare regulations; Medicaid and Medicare audits; Certificate of Need Applications and litigation; licensure, surveys, and certification issues; and HIPAA and privacy laws. Robb also provides counsel to health care providers with complex government contract procurement issues.

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Managed Care Narrow Networks

Narrow networks (managed care provider networks that include a limited choice of participating healthcare providers and suppliers) have been widely criticized by consumers and consumer-rights groups, particularly in light of the number of narrow network products that are included in the ACA exchange marketplace.  Use of narrow networks by self-insured businesses is also growing more prevalent.  For consumers who have multiple options for insurance coverage, the question is often one of choice – am I willing to pay more in premiums in order to continue to see my existing doctor, go to the hospital of my choice, or have a wider range of options if I need to see a specialist?

From the doctor’s perspective, however, narrow networks are very confusing.  In many cases, it is unclear why a particular doctor is, or is not, allowed to participate in the network.  In some cases, only certain physicians are invited to participate in the network, leaving other physicians without knowledge that the plan even exists until a patient calls to find out why the physician does not participate.

While willingness by the physician or physician group to accept the reimbursement rates offered by the payor is one criterion for participation in the narrow network plans, other criteria come into place as well.  An invitation to participate in a narrow network may be based upon the payor’s rating of the ability of the physician to offer quality of care and to provide care efficiency (a cost-based rating system).  The tier and rating systems, however, are not consistent among payors and often criticized for producing inaccurate, irrelevant and unreliable results.  Physicians also worry that there may be a loss of professional autonomy if physicians are pressured, in the course of providing care, to meet the tier and rating criteria developed by the payors in order to participate in the narrow networks rather than to exercise independent medical judgement.

A number of measures have been recently introduced to address consumer-driven concerns with narrow networks.   The Patient Protection and Affordable Care Act – HHS Notice of Benefit and Payment Parameters for 2017 (available here: https://www.federalregister.gov/articles/2015/12/02/2015-29884/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017) proposes that states should be required to develop rules to test the adequacy of provider participants in payor networks.  In addition, the National Association of Insurance Commissioners has been working to update model legislation regarding plan network access and adequacy.  Finally, legislation regarding network adequacy has been adopted or proposed in a number of states.  Typically, state laws incorporate rules regarding maximum travel distances for a patient to see a participating provider, maximum wait-times and/or acceptable provider-to-beneficiary ratios.

If you have questions regarding your relationship with third-party payors, such as managed care contracting, billing audits, or inclusion in narrow networks, Parker Poe has a number of experienced attorneys able to assist.

Joy Hord

Joy Hord

Joy Hord focuses her practice on regulatory and compliance matters specifically related to the health care industry. Her clients include hospitals, physicians, pharmacies and other health care providers. Ms. Hord also has significant experience representing health care professionals and organizations with business law and transactional issues, such as mergers, acquisitions and joint ventures. Ms. Hord leads Parker Poe’s Health Care Practice, which includes attorneys from the firm’s North Carolina and South Carolina offices.

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CMS Releases Proposed Rules on Medicaid and CHIP Managed Care

On Tuesday, May 26, 2015, the Centers for Medicare & Medicaid Services (“CMS”) released the pre-publication proposed rule that updates Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations.  In the accompanying press release, Andy Slavitt, Acting Administrator of CMS, indicated that “[t]his proposal will better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans, to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage.”Read More

Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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