Posts tagged California Healthcare Law.

California’s new Office of Health Care Affordability recently adopted emergency regulations (Final Regulations) implementing the Health Care Market Oversight Program, required under California’s Health Care Quality and Affordability Act (HCQAA). HCQAA, which created the Office of Health Care Affordability (OHCA), requires “health care entities” to provide written notice of certain “material change transactions” to OHCA. (Cal. Health & Safety Code § 127500 et seq.) OHCA may then conduct a cost and market impact review (CMIR), with the overarching goal of ...

Peer Review Hearings Are Not Court Trials: California Reaffirms Flexible Nature Of Fair Procedure

The California Supreme Court recently issued its decision in Boermeester v. Carry.  Though the case deals with fair procedure within a private university’s internal disciplinary proceedings, it provides helpful guidance for peer review bodies navigating medical disciplinary hearings.

Boermeester reiterated the long-standing admonition that courts should not try to impose “rigid procedures” upon private organizations’ administrative proceedings.  Rather, the organizations themselves should develop methods for providing the fundamentals of fair ...

Managed Care Plans Take Note: OIG’s Managed Care Strategic Plan

With the tremendous growth of managed care over the last several years, the Medicare and Medicaid programs have had to transform how they fund health care for approximately 100 million enrollees. According to the Department of Health & Human Services’ Office of Inspector General (OIG), 2022 saw half of Medicare enrollees receive coverage through Medicare Advantage plans. As a result, government spending on Medicare Advantage was $403B, or about 50% of all Medicare funds. Similarly, 81% of current Medicaid enrollees receive some component of their coverage through managed ...

Peer Review or Employment? A Framework for Addressing Physician Performance Issues in Hospitals

COVID-19 accelerated the trend of physician employment with hospitals, with recent data showing that nearly 70 percent of physicians are employed by hospitals or hospital-affiliated foundations or groups.  While physician integration improves quality of care and clinical efficiency, it also blurs the separation of responsibilities between the medical staff and the employer.  This can create headaches for stakeholders who want to address physician performance issues. … 

CA DHCS Announces New MLR Requirements on Subcontractors, Including IPAs, RBOs and RKKs

California’s Department of Health Care Services (DHCS) is in the final stages of establishing new Medical Loss Ratio (MLR) requirements in Medi-Cal Managed Care. Most significantly, the guidelines specify that the MLR program, which previously applied to Medi-Cal managed care plans, will now also apply to certain of their subcontractors, including risk-bearing providers. … 

California Health Plans and Insurers, It’s Time to Prioritize Mental Health Parity Compliance

A recent California First District Court of Appeal (“Court”) decision, Futterman v. Kaiser Foundation Health Plan, Inc., (“Futterman”) has shed light on potential liabilities for noncompliance with the State’s mental health parity requirements.1

As background, the COVID-19 pandemic served as a catalyst for increasing already soaring behavioral health care demand, by intensifying mental health and substance use conditions across the country. In a 2020 survey by the California Health Care Foundation, Californians ranked mental health treatment as their top ...

The COVID-19 Public Health Emergency Has Ended - Now What for Managed Care Plans?

May 11, 2023 marked a milestone in the pandemic response with the expiration of the federal COVID-19 Public Health Emergency (PHE). The expiration of the PHE marks an end to the wide-reaching efforts undertaken by the federal government through emergency declarations, congressional and regulatory actions that provided flexibilities for the healthcare industry to ensure continuous delivery of health services during the PHE. As the Centers for Medicare & Medicaid Services (CMS) explained, while some of these changes are extended or made permanent, others are not. Medicare ...

CMS Attempts to Reduce Appointment Times for Medicaid and CHIP Patients - How Will This Impact Your Managed Care Plan?

A recent survey found that the average wait time for a new patient to see a physician in 15 of the largest cities in the U.S. was 26 days, up from 24.1 days in 2017. Timely access to health care providers has long been an issue, but appears to be worsening in certain geographies and provider types. Until recently, timely access to care was regulated at the state level; however, in April, the Centers for Medicare & Medicaid Services (CMS) unveiled its proposed rule to address the issue. The Notice of Proposed Rulemaking Managed Care Access, Finance, and Quality (CMS-2439-P) (NPRM) only ...

California’s New Apology Law and Its Impact on Peer Review Hearings

Parties in peer review hearings can present a wide range of relevant evidence, regardless of its admissibility in a court of law.  But California has passed a new “apology law” that modifies that standard, erecting a potential hurdle for medical staffs to admit relevant evidence against practitioners in peer review hearings.

Under California law, statements, writings, or benevolent gestures expressing sympathy or a general sense of benevolence relating to the pain, suffering, or death of a person involved in an accident are inadmissible in civil trials.  (Evid. Code, § 1160.)  ...

Anticipating AB 890’s Implementation: Now is a Good Time for Medical Staffs to Get Their Ducks in a Row

Given California’s shortage of primary care providers, nurse practitioners (“NPs”) are increasingly being asked to fill gaps in provider coverage.  With that background, Governor Newsom signed Assembly Bill 890 (“AB 890”) into law in 2020.  AB 890 allows NPs to practice with expanded independence under certain conditions.  Although nearly two years have passed since AB 890 was enacted, regulatory and legislative delay have prevented full implementation of the law.

But that’s expected to change soon.  The Board of Registered Nursing anticipates the law will be fully ...

A Friendly Reminder: Friendly PC Arrangements are Subject to Scrutiny

As healthcare grows increasingly complex, delivery structures continue to evolve.  A popular arrangement is the “Friendly PC” model, where large medical groups are backed by private equity or health system investment and administrative support.  But courts and lawmakers have become concerned that certain Friendly PC arrangements encroach on physician autonomy and violate the century-old prohibition on the corporate practice of medicine (“CPOM”).  A recent lawsuit—American Academy of Emergency Medicine Physician Group, Inc. v. Envision Healthcare Corporation ...

Medical Group Peer Review: The Next Frontier

While hospital medical staffs have traditionally handled most of California’s peer review activity, recent trends are forcing more and more medical groups to wrestle with reporting and fair hearing obligations when disciplining physicians—or else face costly litigation from doctors and six-figure fines from the Medical Board of California.

Broadly speaking, peer review is how healthcare entities—including medical groups—determine whether a physician is qualified to practice in a particular healthcare setting and perform ongoing assessments of that ...

Posted in Managed Care
DMHC and DHCS Fine L.A. Care $55 Million in Enforcement Actions

The California Department of Managed Health Care (DMHC) on March 4, 2022, assessed the largest penalty against a health plan in the Department’s history. DMHC and the California Department of Health Care Services (DHCS) jointly announced the results of enforcement actions against Local Initiative Health Authority for Los Angeles County, more commonly known as L.A. Care. The penalties assessed by DMHC and DHCS against L.A. Care include $55 million in fines, which consist of a $35 million fine from DMHC and a $20 million sanction from DHCS. The amount is by far the largest penalty ...

Posted in HIPAA

When Covered Entities or Business Associates or their counsel analyze whether a particular disclosure of Protected Health Information (or PHI, as defined in HIPAA) is permissible, they should be sure also to analyze whether the disclosure complies with HIPAA’s Minimum Necessary Rule (MNR), which is oft forgot. This issue arises when disclosing PHI in response to subpoenas, which HIPAA permits as long as the disclosing party receives satisfactory assurances that the requesting party has made reasonable efforts to obtain a protective order or to notify the individual(s) who ...

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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