(ROYAL OAK) – Michigan’s health department was assigned to craft a report detailing the impact of potential future federal Medicaid cuts as part of an executive directive Gov. Gretchen Whitmer penned this month at a press event at Beaumont University Hospital.

The U.S. House is considering up to $880 billion in Medicaid cuts over 10 years, which KFF (formerly the Kaiser Family Foundation) projects represents 29 percent of state-financed Medicaid spending per resident, to cover the costs of extending tax cuts President Donald Trump signed in 2017.

U.S. Rep. Debbie Dingell (D-Dearborn) said House Republicans have circled May 7 on the calendar as the day they will roll out more details on the reductions, which she said is not about presenting a balanced budget.

The tax cuts in question come from the Tax Cut and Jobs Act (TCJA) of 2017, which lowered individual income tax rates and increased standard deductions, but also lowered the corporate income tax from 35 percent to 21 percent.

Also joining Whitmer in the hospital’s serene sixth floor atrium were U.S. Reps. Haley Stevens (D-Birmingham) and Rashida Tlaib (D-Detroit), as well as Dr. Dan Carey, president of Corewell Health William Beaumont University Hospital and several other white coats.

Medicaid is the third-largest mandatory program in the federal budget, accounting for 9 percent of federal [Read More]

Nearly nine years ago, Faith Brown watched her armed husband kill her four children after she served him divorce papers. Now she visits the Capitol with a funding request to legislators, saying Michigan’s newest gun laws won’t protect domestic violence survivors if shelters close.

“He killed our four children in front of me. He shot me, cut me with a knife and left me for dead. What was so chilling was how calm he was. He wasn’t angry. He didn’t yell. He just did it,” Brown said. “I remember waking up in the hospital. A social worker gave me a folder with resources to try to help me put my life back together. I still have that folder.”

On April 22, around 100 individuals gathered behind the Capitol to kick off the “Team Enough” lobby day, calling for various firearm reforms.

Some of today’s policy requests were intended to build off statutes adopted by the previously Democratic-controlled state government in the 2023-24 term. For example, in May 2023, the governor signed off on creating Extreme Risk Protection Orders (ERPOs), so family members, spouses and romantic partners could petition the courts to have someone’s guns temporarily confiscated.

Later, in November 2023, the governor signed legislation banning individuals convicted of misdemeanor domestic violence [Read More]

By DANIEL AYYASH & KELSEY CLAUSS
Wachler & Associates, P.C.

Healthcare providers are well aware of the complexities and demands of Medicare audits and the havoc they can wreak. However, with careful billing, attention to detail, and thorough documentation, it is possible to turn the tide. However, a recent trend indicates that Medicare audits are being scrutinized much more closely and are quickly evolving into something far more serious—an investigation under the False Claims Act (FCA).

The Medicare audit process typically involves a review of healthcare claims, medical records, billing codes, and supporting documentation. When alleged discrepancies are found—such as improper coding, overbilling, inaccurate claims, or inadequate documentation—providers may face overpayment allegations, repayment demands, and other related consequences, usually contained within the administrative Medicare framework and not escalated to a matter under the FCA… Until now.

What is the False Claims Act (FCA)?

The FCA is a powerful federal law designed to hold individuals and organizations accountable for submitting fraudulent or false claims for payment from the government. Originally introduced to address unscrupulous government contractors during the Civil War, the FCA has become a popular tool for prosecuting alleged healthcare fraud. Generally, the FCA imposes civil liability for knowingly submitting false claims to the government. The FCA also allows individuals [Read More]

By LEE G. PETRO & KIMBERLY RUPPEL
Dickinson Wright

The future of healthcare once seemed like science fiction—think of The Jetsons, the iconic 1960s animated show where families communicate via video calls and receive virtual checkups. But today, telehealth has rapidly become a reality, thanks to technological advances and broadband expansion. However, key funding mechanisms are now under scrutiny, raising questions about whether this future will continue to grow or stall.

Recent advancements in broadband infrastructure have fueled the rapid expansion of telehealth services. Underpinning this significant growth has been the expansion of the broadband infrastructure over the past five years to ensure that healthcare providers and patients have reliable communications services. However, two significant government actions last week could impact future funding and accessibility.

First, oral arguments were heard on March 26 by the Supreme Court regarding challenges to the Universal Service Fund (“USF”) Program. The USF Program is overseen by the Federal Communications Commission (“FCC”), which delegates the day-to-day operations of the USF Program to the Universal Service Administrative Company (“USAC”). Under the supervision of the FCC, USAC collects mandatory contributions from telecommunications carriers. The contributions fund several subsidy programs, including the Rural Health Care Program. This Program assists eligible healthcare entities in connecting with affordable telecommunications and broadband services. [Read More]

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

El Sayed Handing Out Grades To Kennedy

The former director of the Detroit and Wayne County health departments is awarding two grades to the new federal health director, RFK, Jr.

Dr. Abdul El-Sayed gives Robert F. Kennedy Jr. an A for focusing on the major nutrition problem facing this country, but a D for suggesting the wrong solution.

“He is bringing attention to the long-term problem of nutrition in an industry dominated by huge corporations producing the wrong kinds of foods that are ultra-processed and delivered in ways just to get us to consume more (and) he defines the problem and then brings the wrong solution chaotically and ham-handed to be executed, usually for his own gain.”

Interviewed on Off the Record the day after tossing his hat back into the statewide elective ring, this time for the U.S. Senate, El-Sayed hit a number of bullet points.

– “I don’t second-guess somebody else’s decision-making,” regarding Gov. Gretchen Whitmer’s strategy to work with President Trump when she can.  “A governor’s role is different from what a senator’s role might be,” the former Democratic gubernatorial candidate observed.

– He conceded that President Donald Trump won the “young man disaffected” vote in 2024. El Sayed has a strategy [Read More]

By PAUL NATINSKY
Like the rest of the cuts by chainsaw, the 15-percent cap on indirect costs for National Institutes of Health projects is a sharp-edged reduction in spending. Purportedly targeted at reducing waste and inefficiency, the indiscriminate reduction belies that mission.

The most rudimentary of analyses would have proved the approach infeasible. About $9 billion of the NIH’s $35 billion in grants for 2023 were for indirect costs, which include equipment and office space, technology, research security, data processing, biosafety, financial and accounting support, and legal and compliance support. Indirect costs average around 28%, with some over 60%, according to NIH-reported numbers. The costs are negotiated on a project-by-project basis.

The proposed cuts, which remain under legal challenge, would stop many projects in their tracks. Twenty-two states immediately filed suits in federal court after Trump administration rolled out its plan in early February.

“The NIH funding cuts that were peremptorily imposed (and then stopped by the courts) are terrible for the University and even more so for the state of Michigan and for all of our citizens,” said Marianne Udow-Phillips, a lecturer at the University of Michigan School of Public Health, who has worked in a number of roles during a long career in health policy in Michigan.

The [Read More]

By PATRICIA CALLAHAN

This story first appeared in ProPublica, a nonprofit newsroom that investigates abuses of power.

Leaders at the Centers for Disease Control and Prevention ordered staff this week not to release their experts’ assessment that found the risk of catching measles is high in areas near outbreaks where vaccination rates are lagging, according to internal records reviewed by ProPublica.

In an aborted plan to roll out the news, the agency would have emphasized the importance of vaccinating people against the highly contagious and potentially deadly disease that has spread to 19 states, the records show.

A CDC spokesperson told ProPublica in a written statement that the agency decided against releasing the assessment “because it does not say anything that the public doesn’t already know.” She added that the CDC continues to recommend vaccines as “the best way to protect against measles.”

But what the nation’s top public health agency said next shows a shift in its long-standing messaging about vaccines, a sign that it may be falling in line under Health and Human Services Secretary Robert F. Kennedy Jr., a longtime critic of vaccines:

“The decision to vaccinate is a personal one,” the statement said, echoing a line from a column Kennedy wrote for the Fox News website. [Read More]

By JESSE ADAM MARKOS, ESQ.
Wachler & Associates, P.C.

Michigan is currently facing a shortage of physicians, especially in the state’s many rural and underserved areas.  In response, efforts are being made to remove barriers to entry for high-quality providers, like the often-confusing licensing process across state lines.  More specifically, the Michigan Legislature has recently taken action to renew Michigan’s standing as part of the Interstate Medical Licensure Compact (“ILMC”) and to ensure that it can remain within the compact permanently.  The ILMC streamlines the licensing process for physicians seeking to practice across state lines and has proven successful in increasing access to care.  However, Michigan’s participation in the compact is currently set to expire March 28, 2025 and lawmakers must move quickly before it expires.

Michigan first joined the ILMC in 2018 when Governor Snyder signed Public Act 524 of 2018 and Public Act 563 of 2018, making Michigan the 25^th state to join compact.  Currently, 35 states participate as members.  The ILMC allows physicians who are licensed in other member states the ability to get licensed easier in Michigan based on having a compact license.  It also allows Michigan physicians to get licensed easier in other member states.

Pursuant to the ILMC, a licensed physician in Michigan [Read More]

By NICOLETTE TABER
Dickinson Wright

On January 17, 2025, the U.S. Departments of Labor, Health and Human Services, and the Treasury (“the Departments”) issued their 2024 Report to Congress on the enforcement and implementation of the Mental Health Parity and Addiction Equity Act (“MHPAEA”). This regularly required report follows the Departments’ Final Rules issued in September 2024. (For more information on the September 2024 Final Rules, click here to read my previous article on this topic).

The 142-page report to Congress highlights the Departments’ efforts to strengthen and enforce the protections of MHPAEA, the Departments’ efforts to raise awareness of MHPAEA by working with federal and state partners, and areas of improvement for plans and issuers. Notably, the report reviews the enforcement efforts performed by the Department of Labor’s Employee Benefits Security Administration (“EBSA”) and the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (“CMS”) and their impact on the Departments’ efforts to effectuate mental health parity.

EBSA has primary enforcement jurisdiction over MHPAEA for approximately 2.6 million private, employment-based group health plans covering roughly 136 million Americans. Nearly 25 percent of its enforcement program focuses on MHPAEA nonquantitative treatment limitations (“NQTL”). CMS has enforcement authority over approximately 91 thousand non-federal governmental plans [Read More]

Possible Federal Cuts To Medicaid, Education Always On Flood’s Mind

State Treasurer Rachael Eubanks and State Budget Office Director Jen Flood said they have been watching the federal government “daily” to see if any changes could hit what the state expects in their 2026 budget.

Speaking at an Institute for Public Policy and Social Research (IPPSR) event, Flood said she has seen proposed federal cuts to nearly $900 million in Medicaid funding and a possible 10 percent removal from education in federal grant funding because of the dismantling of the U.S. Department of Education.

“I can say Medicaid is on my mind every day right now. Michigan is one of the states that actually draws down more federally than a lot of others,” Flood said.

She said the federal government was looking to wrap up reconciliation before Easter, but she didn’t know if or when it would happen.

“Hopefully these changes are out away, so we have some time to figure out how it would impact the state, but we’ve got to start preparing for different scenarios,” she said.

Flood said Gov. Gretchen Whitmer’s current budget still stood because there were no federal changes that had been passed federally. If that happened, it would cause a “recalibration” of the budget, even if it [Read More]

By PAUL NATINSKY

As Robert F. Kennedy eases into the Health and Human Services director’s chair, his flashpoints and shortcomings are widely publicized, but lightly opposed.

Kennedy’s skeptical views on vaccine effectiveness and safety, fondness for fringe conspiracy theories and likely embrace of deep Medicaid cuts have the healthcare community and many policymakers concerned about the new secretary’s public health stewardship.

Kennedy’s lack of administrative acumen looms large as he assumes control over a department that employs 80,000 and oversees a $3 trillion annual expenditure representing 22.8% of the U.S. federal budget.

Kennedy lacks managerial experience at organizations even a small fraction of that size. HHS is responsible for the care of 140 million Americans. That number is largely made up of the country’s most vulnerable citizens, including people too poor to afford to buy health insurance, those whose employers don’t offer coverage, and people over age 65 or who have disabilities.

Yet, despite these glaring warning signs, the healthcare community is oddly silent or seemingly eerily reassured.

Nationally, the online news outlet Politico could round up only a handful of healthcare insiders to comment under a veil of anonymity. Only the American Public Health Association spoke on record.

“They think he’s the wrong person for the job,” Dr. Georges Benjamin, executive [Read More]

By PHIL GALEWITZ

Medicaid is under threat — again.

Republicans, who narrowly control Congress, are pushing proposals that could sharply cut funding to the government health insurance program for poor and disabled Americans, as a way to finance President Donald Trump’s agenda for tax cuts and border security.

Democrats, hoping to block the GOP’s plans and preserve Medicaid funding, are rallying support from hospitals, governors, and consumer advocates.

At stake is coverage for roughly 79 million people enrolled in Medicaid and its related Children’s Health Insurance Program. So, too, is the financial health of thousands of hospitals and community health centers — and a huge revenue source to all states.

On Feb. 13, the House Budget Committee voted to seek at least $880 billion in mandatory spending cuts on programs overseen by the House Energy and Commerce Committee. That committee oversees Medicaid, which is expected to bear much of the cuts.

Senate Republicans, working on their own plan, have not proposed similar deep cuts. Sen. Ron Wyden of Oregon, the Finance Committee’s top Democrat, said he expects “an effort to keep the Medicaid cuts hidden behind the curtain, but they’re going to come sooner or later.”

Since Trump took office, Republicans in Washington have discussed making changes to Medicaid, particularly by requiring [Read More]

By AMY MAXMEN

Some private schools have shut down because of a rapidly escalating measles outbreak in West Texas. Local health departments are overstretched, pausing other important work as they race to limit the spread of this highly contagious virus.

Since the outbreak emerged three weeks ago, the Texas health department has confirmed 90 cases with 16 hospitalizations, as of Feb. 21. Most of those infected are under age 18. Officials suspect that nine additional measles cases reported in New Mexico, across the border from the epicenter of the Texas outbreak in Gaines County, are linked to the Texas outbreak. Ongoing investigations seek to confirm that connection.

Health officials worry they’re missing cases. Undetected infections bode poorly for communities because doctors and health officials can’t contain transmission if they can’t identify who is infected.

“This is the tip of the iceberg,” said Rekha Lakshmanan, chief strategy officer for The Immunization Partnership in Houston, a nonprofit that advocates for vaccine access. “I think this is going to get a lot worse before it gets better.”

An unknown number of parents may not be taking sick children to clinics where they could be tested, said Katherine Wells, the public health director in Lubbock, Texas. “If your kids are responding to fever reducers and [Read More]

By STEPHEN SHAVER
Consultant, Wachler & Associates PC

Nearly every third-party payor of claims for healthcare services – Medicare, Medicaid plans, commercial insurers, etc. – will at some point request that the billing provider submit copies of the documentation and medical records that support the services billed. In these circumstances, an ounce of prevention is often worth a pound of cure. The payor will often make decisions regarding coverage and overpayment allegations based on the records submitted by the provider. The provider can proactively address or even prevent many disputes by careful attention to their response to the medical records request.

First, a provider should be aware of what entity issued the request, what specific records it has requested, and for what purpose. For example, a Medicare Unified Program Integrity Contractor (“UPIC”) is charged with investigating allegations of fraud within the Medicare program and may conduct a records review differently from other Medicare contractors. The Special Investigation (“SI”) unit or team at many commercial insurers serves much the same function. The provider is generally required to comply with the request for records, whether by law, regulation, or contractual agreement. It is, therefore, important to carefully review the record request and provide documentation that is responsive. Where the request [Read More]

By ERICA ERMAN
Dickinson Wright

Can you remember healthcare security 20+ years ago? It seems like a different world from now. Believe it or not, the HIPAA Security Rule has barely changed since it was first enacted in 2003[1]and has been long overdue for a significant remodel. Read on for highlights of the proposed new Security Rule and action items.

A Very Brief HIPAA History

 As a quick background, the HIPAA Security Rule was first penned in large part to create minimum security standards for electronic protected health information (ePHI) and to protect patients’ rights over their healthcare data. The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 added the now well-known Breach Notification Rule as well as other significant changes in an effort to protect patient information. As healthcare professionals well know, much of the onus of protecting that information has fallen on HIPAA-covered entities and providers.

Questions, Concerns, Complaints – Comment Period Is Open

On January 6, 2025, the proposed new HIPAA Security Rule was added to the Federal Register. For any of our readers interested in filing comments to the proposed rule, please note that the comment period is open until March 7, 2025 (60 days after the proposed rule was [Read More]

Richardville Urges Leadership, Bi-Partisan Cooperation To Address ‘Mental Health Crisis’

Back in 2014, then-Senate Majority Leader Randy Richardville put together a $1.5 billion road funding plan with higher fuel taxes, among other things. He said the incentive at the time was what he was hearing in his district.

“I think the most common phrase I’m hearing from back home is ‘just fix the roads. In fact, they say ’just fix the damn roads,” Richardville is quoted in an MLive article as saying.

Richardville was before his time in coining that catchphrase. His counterpart in the Senate at the time, Democratic Leader Gretchen Whitmer, used the slogan during her gubernatorial campaign with success.

But like Whitmer, Richardville wasn’t able to get any traction on this plan. Gov. Rick Snyder and House Speaker Jase Bolger gave it a frosty response and the issue carried over into the next term.

Now, with House Speaker Matt Hall (R-Richland Township) putting out a revamped proposal using existing revenue and now-Gov. Whitmer slated to come out as soon as Monday with a road funding plan that she has said will be a mix of new revenue and cuts, Richardville feels bipartisanship may be back in the air.

And that’s what brings the former Senator from Monroe back to Lansing. Richardville was the guest on [Read More]

By STEPHANIE ARMOUR

Former President Donald Trump’s return to the White House will likely bring changes that scale back the nation’s public health insurance programs — increasing the uninsured rate, while imposing new barriers to abortion and other reproductive care.

The reverberations will be felt far beyond Washington, D.C., and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health. Abortion restrictions may tighten nationwide with a possible effort to restrict the mailing of abortion medications.

And with the elevation of vaccine skeptic Robert F. Kennedy Jr. to Trump’s inner circle of advisers, public health interventions with rigorous scientific backing — whether fluoridating public water supplies or inoculating children — could come under fire.

Trump’s return will give a far broader platform to skeptics and critics of federal health programs and actions. Worst case, public health authorities worry, the U.S. could see increases in preventable illnesses; a weakening of public confidence in established science; and debunked notions — such as a link between vaccines and autism — adopted as policy. Trump said in an NBC News interview on Nov. 3 that he would “make a [Read More]

This year, Michigan hospitals will continue pushing legislators to ban drug manufacturers from creating restrictions and limited-access conditions around their “340B Drug” products, which they say will preserve discounted drug access for rural hospitals.

The federal 340B Drug Pricing Program was established in 1993. According to the federal Health Resources and Services Administration, drug manufacturers participating in the Medicaid insurance program must supply outpatient drugs to 340B facilities at “significantly reduced prices.” Becoming a 340B facility depends on the number of Medicaid recipients and considerably “underserved” individuals that a hospital serves.

In a recent interview with MIRS, Laura Appel – the Michigan Health and Hospital Association’s executive vice president – said 87 hospitals in the state were 340B hospitals at the time.

She spoke to MIRS while the Senate was wrapping up its overnight, 29-hour Senate session. However, as she observed the Capitol from her office window, she admitted that one of the biggest bills MHA most wanted to be passed in the 2023-24 term was dead.

Right now, states like Arkansas, Louisiana, Mississippi and Missouri outlaw drugmakers in their state from putting up “340B Contract Pharmacy Restrictions.” On Dec. 13, the Senate passed a bill 30-5 – with three senators not voting – prohibiting manufacturers from setting up guardrails in their 340B contracts.

The [Read More]

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

Whitmer Signs Maternal Health Package, Pharmacist Birth Control Bills, Other Insurance Changes

Gov. Gretchen Whitmer signed 16 bills this month, many surrounding women’s reproductive health care, including two that let pharmacists prescribe birth control, a nine-bill package putting pregnancy on Medicaid, and two on birthing centers and doulas.

Whitmer was slated to sign HB 5435 and HB 5436 in Flint today, but the event was canceled because of the snow and freezing weather. Whitmer posted the signing on social media, where she thanked Reps. Stephanie Young (D-Detroit) and Kara Hope (D-Holt) for sponsoring the bills.

“Today, I’m signing commonsense bills to further protect everyone’s fundamental freedom to make their own decisions about their own body,” Whitmer said. “These bills will save women time and money so they can access the birth control they need and cut unnecessary red tape that stands between people and their health care.”

The bills would not only allow pharmacists to prescribe birth control, but would also require insurance to cover birth control, as well.

The bills passed along party lines and Republicans voiced their opposition to the bills, opening the guidelines to allow prescriptions regardless of age.

Planned Parenthood of Michigan applauded the passage of the two bills.

“As [Read More]

By ROLF LOWE
Wachler & Associates

On Dec. 18, 2024, the Center for Medicare and Medicaid Services, announced that Michigan, along with New York, Oklahoma and South Carolina were selected to participate in the Innovation in Behavioral Health (IBH) Model. The IBH Model is another step forward by CMS in integrating health care services and improving outcomes for Medicare and Medicaid beneficiaries. The IBH Model was announced in January of 2024 with CMS providing funding opportunities for state Medicaid agencies willing to participate in the IBH Model. The Implementation of the IBH Model started on January 1, 2025, and is scheduled to be in effect for eight years.

The IBH Model in Michigan is being implemented in designated sub-state geographic service areas. The provider participants in the in the IBH Model are specialty behavioral practices, community mental health centers, opioid treatment programs and public or private practices where individuals can receive outpatient mental health or Substance Use Disorder (SUD) services or both. The IBH Model refers to the providers as practice participants. The Michigan Department of Health and Human Services (MDHHS) intends to implement the IBH Model in both urban and rural areas. Providers being selected to become practice participants in the IBH Model are those that [Read More]

By GLENN S. RICHARDS & LEE G. PETRO
Dickinson Wright

Introduction

On December 13, 2024, the Federal Communications Commission (FCC) announced significant updates to its Mapping Broadband Health in America platform. This enhanced tool, now incorporating a range of new health metrics, aims to provide deeper insights into the connection between expanding broadband connectivity and critical health outcomes, with a particular focus on maternal health.

Background

The FCC administers two healthcare subsidy programs under its Universal Service Fund: the Rural Health Care (RHC) program and the COVID-19 Telehealth program. The RHC program provides funding to eligible health care providers to support the cost of broadband and telecommunications services that enable telehealth and telemedicine. The COVID-19 Telehealth program was created during the pandemic to provide funding to eligible health care providers to purchase telecommunications services, information services, and connected devices to provide connected care services to patients in response to the COVID-19 pandemic.

In addition to these efforts, the FCC’s Mapping Broadband Health in America platform was launched to visualize and analyze the relationship between broadband access and chronic diseases. The platform has evolved to address various public health challenges, including opioid abuse and maternal health. The latest update significantly expands the platform’s capabilities, making it a valuable [Read More]

Michigan’s public mental health plans filed a lawsuit accusing the state’s Department of Health and Human Services of imposing unnegotiated contract terms and threatening to cut off funding.

The plans, known as prepaid inpatient health plans argued DHHS’ actions violate state law and jeopardize mental health and substance use disorder services for thousands of residents.

“This isn’t just a contract dispute – it’s about ensuring the stability of behavioral health services that families across the state rely on every day,” said Robert Sheehan, chief executive officer of Community Mental Health Association of Michigan.

The six-count complaint, filed on behalf of NorthCare Network Mental Health Care Entity and Northern Michigan Regional Entity in the Court of Claims, alleges in part violation of the Headlee Amendment, and the PIHPs seek a writ compelling the state to continue providing Medicaid and general funds to the PIHPs as well as retraction of any communications and actions “taken to terminate the relationship between DHHS and plaintiffs.”

The plaintiffs, who want a preliminary injunction prohibiting DHHS from withholding substance abuse disorder health home services funding, also want a hearing to dispute DHHS’ decision to terminate contracts and they seek unspecified damages.

DHHS said in a late statement that “the Michigan Department of Health and Human Services is [Read More]

By ANNIE WALDMAN

This story was originally published Nov. 19, by ProPublica, a nonprofit newsroom that investigates abuses of power.

For years, it was a mystery: Seemingly out of the blue, therapists would feel like they’d tripped some invisible wire and become a target of UnitedHealth Group.

A company representative with the Orwellian title “care advocate” would call and grill them about why they’d seen a patient twice a week or weekly for six months.

In case after case, United would refuse to cover care, leaving patients to pay out-of-pocket or go without it. The severity of their issues seemed not to matter.

Around 2016, government officials began to pry open United’s black box. They found that the nation’s largest health insurance conglomerate had been using algorithms to identify providers it determined were giving too much therapy and patients it believed were receiving too much; then, the company scrutinized their cases and cut off reimbursements.

By the end of 2021, United’s algorithm program had been deemed illegal in three states.

But that has not stopped the company from continuing to police mental health care with arbitrary thresholds and cost-driven targets, ProPublica found, after reviewing what is effectively the company’s internal playbook for limiting and cutting therapy expenses. The insurer’s strategies are [Read More]

 By JENNI COLAGIOVANNI
Wachler & Associates, P.C.

The COVID-19 Public Health Emergency (PHE) resulted in the waiver of certain pre-pandemic restrictions to expand Medicare coverage of telehealth services and increase access to care for Medicare patients.  More than a year and a half after the end of the PHE, several of these continuing telehealth flexibilities are set to expire on December 31, 2024, returning Medicare coverage of some telehealth services back to their pre-pandemic requirements.

Background: Prior to the COVID-19 pandemic, Medicare coverage of telehealth services was primarily limited to patients located in rural areas and restricted to certain provider types and services. Patients were generally required to travel to approved clinical sites to engage in telehealth services from providers in other locations. Early in the pandemic, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) broadened the Secretary of the Department of Health and Human Services’ waiver authority under section 1135 of the Social Security Act.  Pursuant to this broadened authority, CMS waived the requirements of section 1834(m)(4)(E) of the Act and 42 CFR § 410.78 that specified the types of “distant site” practitioners that could bill Medicare for telehealth services to include all practitioners eligible to bill Medicare for their professional [Read More]

By KIMBERLY J. RUPPEL
Dickinson Wright

As is the case in many industry sectors, the end of the year brings us to wonder what is in store for healthcare in 2025. Although the future is anyone’s guess, the following three areas of healthcare are most likely to experience robust activity.

1. Non-Compete Litigation

Non-compete provisions are designed to prohibit an employed or contracted healthcare provider from competing against the contracting entity by working for or starting a competing business within a particular geographic area for some time. In April 2024, the Federal Trade Commission (“FTC”) promulgated a rule (the “Rule”) generally prohibiting non-compete clauses in employment agreements except for certain “Senior Executives” with policy-making authority who were compensated greater than $151,164 per year. There was also an exception for non-compete agreements entered into as part of a sale of a business. That Rule was to become effective September 4, 2024. However, a number of lawsuits were filed seeking to prevent its application.

• Fifth Circuit Appeal Ryan

In this case, the plaintiffs argued the FTC exceeded its statutory authority in promulgating the Rule and asked the court to declare the Rule illegal, and the court agreed. As a result, the court determined the Rule was not enforceable nationwide. The FTC [Read More]