Posts tagged Centers for Medicare & Medicaid Services.
Colorado's Peer Review Privilege in Peril

The confidentiality of medical staff peer review has long been a cornerstone of hospital operations, fostering an environment where physicians can candidly evaluate medical care without the looming specter of malpractice exposure.  But this established norm is facing a new threat in Colorado, where a ballot proposal aims to gut peer review confidentiality.

The Foundation of Peer Review Confidentiality

Peer review is a process in which physician conduct that endangers patients within a hospital can be immediately reviewed by peers.  Peer review’s goal is to promote continuous ...

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 ...

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 ...

Proposed Changes to the Health Breach Notification Rule

On May 18, 2023 the Federal Trade Commission (FTC) released a Notice for Proposed Rule Making (NPRM) for updates to the Health Breach Notification Rule, 16 C.F.R. Part 318 (the Rule). The Rule serves to ensure entities that are not defined as Covered Entities under the Health Insurance Portability and Accountability Act (HIPAA) are nevertheless accountable when the sensitive health information of consumers is compromised and that entities cannot conceal breaches from consumers. The Rule imposes notification requirements for a breach of unsecured identifiable health ...

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 ...

Posted in Managed Care
Understanding the HHS 2023 Proposed Rule

The Department of Health and Human Services (HHS) released its Notice of Benefit and Payment Parameters for the 2023 Proposed Rule on January 5, 2022. Generally, the proposed rule aims to bolster the regulatory framework supporting the marketplace and expand access to health insurance coverage options. 

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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