Posts in Managed Care.
How to Prevent an OFAC Sanction When Responding to a Ransomware Attack

A ransomware attack is a major threat affecting all sectors of business, including healthcare. Organizations typically follow state and federal privacy laws as part of their ransomware prevention and response measures. Beyond these privacy laws, every organization should also be aware of U.S. sanctions law in its response to a ransomware attack.

As a reminder, on October 1, 2020, the U.S. Department of Treasury Office of Foreign Asset Control (OFAC) issued an advisory warning regarding the risk associated with making a ransomware payment. Federal laws prohibit U.S. persons or ...

Posted in Managed Care
What to Expect When Selling a Physician Practice

For various reasons, a medical group may decide that it is time to sell their practice. This could be due to reduced reimbursements, increased operational complexities or the desire to “cash out” and retire. When considering a sale, practice leadership should take the following steps to ensure maximum benefit to the physicians in the practice …

Can Businesses That Rent Office Space Enforce COVID-19 Protocols on Landlords?

As the COVID-19 vaccine rollout continues, and the rate of newly recorded infections is starting to decline, many California counties are moving to less restrictive tiers and lifting restrictions applicable to the business environment. A hot topic for many employers has been developing COVID-19 protocols and vaccine requirements for employees returning to corporate office buildings. (See “Can a Healthcare Provider Require Employees to Take a COVID-19 Vaccine?” for protocol guidelines.) Some healthcare businesses that utilize both traditional office space and medical ...

Can a Healthcare Provider Require Employees to Take a COVID-19 Vaccine?

As pandemic restrictions begin to lift and the prospect of employees returning to the workplace becomes a reality, many employers are wondering, whether they can or should make the COVID-19 vaccine a mandatory requirement as a condition of employment or continued employment. The short answer is, per recent EEOC guidance, employers can require employees to be vaccinated, subject to certain exceptions, requirements and caveats discussed below. However, a critical issue is whether employers should mandate COVID-19 vaccinations … 

New Disclosure Requirements for Those that Contract with ERISA Group Health Plans

Included within the 5539 pages of statutory changes in the Consolidated Appropriations Act, 2021 (the COVID-19 relief bill signed into law at the end of December 2020) are important new “transparency” laws that affect third party administrators and other providers who contract with ERISA-regulated group health plans for certain brokerage and consulting services … 

Cities Consider Creating Their Own Public Health Departments

In response to public health restrictions ordered by county health departments and the resulting disruption of local business, a number of California cities are exploring whether or not to create their own health departments. While city health departments were common in California during the 1800s and early 1900s, most cities deferred this governmental function to the better-equipped county … 

Posted in Managed Care
Yes! Even You May Be a Health Care Service Plan….

Well, not exactly. However, in an expansion of regulatory oversight, the Department of Managed Health Care (DMHC) finalized a new rule last year broadening the scope of “person[s]” required to obtain a license under the Knox-Keene Act. The new rule, 28 CCR Section 1300.49, is likely the most significant policy development in California managed care oversight since the enactment of laws governing risk bearing organizations in the late 1990s. Absent legislative or further regulatory action, any entity accepting any amount of global risk in exchange for a prepaid or periodic ...

Understanding the Department of Managed Health Care’s Response to COVID-19

On March 5th, the Department of Managed Health Care (DMHC) issued its first COVID-19 related All-Plan Letter (APL 20-006) regarding screening and testing. The DMHC directed all full service commercial and Medi-Cal health care service plans to immediately reduce cost-sharing to zero for all medically necessary screening and testing for COVID-19. Of note, the APL directed that health plans “ensure” provider networks are adequate to handle an increase in the need for healthcare services, including offering access to out of network services as COVID-19 cases increase. The ...

Posted in Managed Care

Effective January 1, 2019, Health & Safety Code Sections 11161.5, 11162.1, and 11165 were amended to, among other things, provide that the Department of Justice implement a system by which prescription forms for controlled substance prescriptions should each have a uniquely serialized number."

The statutory amendments established the way in which the prescription forms must be printed, the various features that the prescription forms must include, and the way in which the dispenser of controlled substances must report the serial number to the Controlled Substance Utilization ...

Posted in Managed Care

In a decision that facilitates flexible staffing practices for healthcare employers, the California Supreme Court recently held that healthcare workers can legally waive a second meal period when they work shifts longer than 12 hours. Gerard v. Orange Coast Mem'l Med. Ctr., 430 P.3d 1226 (Cal. 2018). The high court’s decision finally and conclusively resolves a contentious and technical dispute over labor enactments that had been the subject of several prior appellate rulings. See our prior discussion re Gerard II here.

Plaintiff healthcare workers alleged that their ...

Starting October 2, 2018, health care practitioners authorized to prescribe, order, administer, or furnish a controlled substance must query, or consult, the Controlled Substance Utilization Review and Evaluation System (CURES) database and run a Patient Activity Report (PAR) on each patient the first time the patient is prescribed, ordered, or administered a Schedule II-IV controlled substance. First time is defined as the initial occurrence in which a health care practitioner intends to prescribe, order, administer, or furnish a controlled substance to a patient and has ...

Posted in Managed Care

Unfortunately, 2017 will most likely be remembered as the Year of Sexual Harassment. Notwithstanding that AB 1825 mandated harassment prevention training in California in 2004, the statute was amended to require training on bullying and abusive conduct in 2015 (AB 2053), and recently to require training in 2018 on gender identity, gender expression, and sexual orientation (SB 396), sexual harassment continues to permeate the work place.  Given the profound impact sexual harassment has on individuals and workplaces, it is time for change.

As a new year begins, this is an ...

Posted in Managed Care

SynerMed, a Southern California-based physician management company, will be shutting down, per an email from its CEO earlier this month. Recently, the company had come under increasing scrutiny by health plans and California state regulators, including an investigation by the Department of Managed Health Care.

According to the company-wide email, audits conducted by health plans had found several system and control failures within medical management and other departments. Additionally, the California Department of Managed Health Care’s investigation has been publicly ...

Posted in Managed Care

On January, 1, 2018, The Joint Commission’s (TJC) new and revised pain assessment and management standards go into effect for TJC accredited hospitals. The changes to the standards stem from a review commenced by The Joint Commission in 2016 to bring the preceding accreditation standards into alignment with leading practices in pain assessment and management, and the safe use of opioids. In light of these standards, hospitals and their medical staffs should review their current policies, protocols, and procedures to ensure their practices comply with the new TJC requirements.

A new California law (AB 72) limits the amount that out-of-network surgeons and other health care professionals may bill patients for covered non-emergency services provided at a contracted facility, such as an ambulatory surgery center.  California’s surprise medical bill law went into effect on July 1, 2017.  It is intended to prevent a consumer from receiving an unexpected medical bill from a non-contracted provider as follows:

  • A patient who is enrolled (Enrollee);
  • In a health care service plan or health insurance policy (Plan);
  • Receives health care services covered by the ...

Recently, the Medical Board of California circulated an open letter, known as a Prescriber Guidance Letter to all practitioners in California who prescribe opiates.  The letter was authored by a statewide workgroup on Prescription Opioid Misuse and Overdose Prevention.  The workgroup includes the Medical Board of California, the Board of Pharmacy, the California Department of Public Health, the DEA, DMV, California Department of Justice, California Health and Human Services, California Society of Addition Medicine, and California Healthcare Foundation, among others.

The ...

Posted in Managed Care

In a rare move, the California Court of Appeal reversed itself and validated a California hospital’s policy of allowing healthcare workers to waive an otherwise mandatory second meal period on shifts longer than 12 hours.  In reversing itself, the California Court of Appeal in Gerard v. Orange Coast Memorial Medical Center (Gerard II) held that its previous decision in Gerard v. Orange Coast Memorial Medical Center (Gerard I), partially invalidating healthcare meal waivers, was incorrect.

California Labor Code section 512(a) requires that two meal periods be provided for any ...

Posted in Managed Care

A proposed rule intended to stabilize the individual and small group insurance markets was issued on February 17, 2017, only a week after the Senate confirmed Tom Price as the Secretary of the U.S. Health and Human Services Department (HHS).[1] Although the proposed rule is intended to stabilize these markets, it may make it more difficult for individuals to obtain and maintain health insurance coverage, thereby reducing the number of people who are insured.

This is a turbulent time for American healthcare. Within weeks after the publication of the proposed rule, the American ...

On January 19, 2017, the Federal Trade Commission announced a settlement which would resolve allegations that competing ophthalmologists violated federal antitrust laws when they refused to negotiate contracts with MCS Advantage, Inc. (MCS), a Medicare Advantage Plan, and Eye Management of Puerto Rico (Eye Management), MCS’s network administrator.

According to the complaint, the charges arise from an arrangement between Eye Management and MCS entered into in April, 2014.  Eye Management agreed to create and manage a network of ophthalmologists to provide services to MCS enrollees and to do so at a cost savings to MCS.   Eye Management planned to replace MCS’s existing contract with each individual ophthalmologist with a new contract between Eye Management and the ophthalmologist at a lower reimbursement rate. In early June 2014, Eye Management sent a proposed contract to every ophthalmologist contracted with MCS at the time. These contracts offered payments at rates that were about 10% lower, on average, than the rates under the existing contracts between MCS and each ophthalmologist.

Posted in HIPAA, Managed Care

As the clock struck midnight on New Year’s Eve, a number of new California laws took effect.  Here are three that California hospital executives need to know:

  • Notice of Observation Status (SB 1076)

    When a patient is being cared for in an inpatient unit of a hospital (or in an observation unit) the hospital must provide the patient with a written notice when the patient is in observation status.  The notice must inform the patient that the observation care is being provided on an outpatient basis and that this may affect the patient’s health care coverage reimbursement.  There are also ...

Our Health Law Ticker is a one-stop resource for everything new and noteworthy in healthcare law. We cover recent developments in healthcare legislation, healthcare reform, Medicare/Medicaid, managed care, litigation, regulatory compliance, HIPAA, privacy, peer review, medical staffs and general business operations for healthcare companies and licensed healthcare professionals.

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