By EMMARIE HUETTEMAN
For the first time since passing the Affordable Care Act, Democrats will soon control the House of Representatives and its powerful health committees. But Republicans’ tightened grip on the Senate means those hoping for another round of dramatic, progressive reforms may be disappointed.

Empowered by voters outraged over Republican attempts to chip away at the law’s protections for the sick, Democrats owe much of their midterm takeback to health care issues. And Democratic leaders say they are ready to get back to work, this time training their sights on skyrocketing drug prices, among other policy conundrums, with a majority of House votes and a slate of new committee chairmanships [Read More]

By EWA MATUSZEWSKI
At this risk of entertaining numerous strategic partnership requests following the publication of this blog, I want to explore the benefits of partnerships that may or may not have financial benefits, yet bring the strengths of two or more parties together for the greater good.

What has me thinking of partnerships in general is the soon-to-be launched integrated primary care clinic our PO is opening at the Warren location of the Judson Center. Judson Center provides autism programs, behavioral health services, child and family services including foster care and adoption, and disability support services throughout Southeast Michigan. With the opening of the clinic, they can add primary care to [Read More]

By SARAH HILLEGONDS
In August, the Provider Reimbursement Review Board released 90 pages of updated rules governing its appeals process. The rules were issued with immediate effect and apply to all pending and future appeals. If a provider fails to comply with these new rules, the PRRB has discretion to dismiss the appeal.1 Because appeals before the PRRB are typically high-value cases, it is critical that attorneys and providers that have cases before the PRRB understand the rule changes.

As background, the PRRB is an independent adjudicating body of the United States Department of Health and Human Services to which a Medicare Part A provider may appeal if dissatisfied with a “final [Read More]

By GREGORY W. MOORE & ALEXANDRA A. HALL
Forty-eight thousand Americans were lost to opioid overdoses in 2017. Michigan opioid-related deaths and overdoses rank 18th-highest in the nation. Over the last year, significant attention was dedicated toward combating this widespread issue on both a federal and state level.

Michigan

Recently enacted Michigan opioid laws were executed with the intent to save lives and decrease misuse of controlled substances. In effect, the laws have imposed significant administrative hurdles and led to some confusion among prescribers, pharmacists, and patients.

The new laws impose substantial obstacles for prescribers prior to writing a prescription for opioids. Among such obstacles include the requirement that when a prescriber [Read More]

Enviro Groups Call Out Schuette For PFAS Response
Environmental groups took Attorney General Bill Schuette to task last month for “dragging his feet” on per- and polyfluoralkyl substances (PFAS) contamination in Michigan—behavior they compare to his response to the Flint water crisis.

Sierra Club Michigan Chapter Chair David Holtz said Schuette “is failing communities all across Michigan” and Bob Allison, deputy director at the Michigan League of Conservation Voters, called it “yet another example of inaction from our government—despite multiple warnings.”

“He’s sitting on PFAS contamination complaints just like he chose not to act on reports of lead in Flint’s drinking water,” Holtz said. “Attorney General Schuette had the authority to take legal [Read More]

By EWA MATUSZEWSKI
Did you hear my heart go thud? As I write this, I just read of Beaumont’s plan to open 30 urgent care centers in Metro Detroit by the end of 2019 with an out-of-state urgent care clinic operator. It’s not a new concept, just more of the same; yet I fear the proliferation of urgent care clinics may lead to the demise of the Patient Centered Medical Home and its focus on patent-centric, whole person coordinated care.

We want everything fast: our information, our food, our relationships… but should we slow down just a bit here and think about the patient/physician bond that is formed through the years, through [Read More]

By PAUL NATINSKY
This summer featured continued disruption in aspects of the Affordable Care Act. This time, the vehicle was suspended risk adjustment payments to health plans. The payments have since resumed, but the methodology used to determine them has come under question.

So-called “risk adjustment” payments were established in the ACA to stabilize the health insurance market by transferring money to plans serving higher risk patients from those serving lower risk patients. The total in transfers for 2017 is $10.4 billion.

Two lawsuits, one in Massachusetts and one in New Mexico, declared the methodology used to determine payments respectively legal and then illegal. These lawsuits prompted CMS to issue a final rule [Read More]

Editor:

Read your paper for the first time (Sept., 2018 issue), picked it up at U of M hospital.
Interesting letter to the editor by Allan Dobzyniak, MD. Apparently, he needs to research exactly what Medicare for all means. If he seriously thinks that doctors and other providers won’t be paid, he is mistaken. He also claims that socialized medicine, as he refers to it does not work and is akin to slavery. Funny, I don’t see any ofthe countries that have socialized medicine taking steps to get rid of it. Socialized medicine is a term some like to use to scare people and whether we admit it or not, we already [Read More]

Erin Diesel Roumayah, Esq.
Wachler & Associates, P.C.

In June, the Office of Medicare Hearings and Appeals (OMHA) publicly implemented an expanded Settlement Conference Facilitation program. SCF is an alternative dispute resolution process which provides appellants and the Center for Medicare and Medicaid Services an opportunity to discuss a mutually agreeable resolution for claims appealed to the Administrative Law Judge (ALJ) or Medicare Appeals Council levels of appeal. This program applies mediation principles to resolve eligible Medicare appeals in an expedient and efficient manner. Through this program, an OMHA senior attorney or program analyst trained in mediation techniques acts as a neutral facilitator between the appellant and CMS in a one-day [Read More]

By ERICA MORRIS, GREGORY MOORE AND RUSSELL KOLSRUD
Mental Health Parity Really Does Mean Equal Benefits
By Erica Morris, Gregory Moore and Russell Kolsrud

In Danny P. v. Catholic Health Initiatives, 891 F.3d 1155 (9th Cir. 2018), the Ninth Circuit clarified the full extent of the “parity” required in the federal mental health parity law1 which has been in place since 2008.

In Danny P., the Ninth Circuit held that a particular group health plan (the Catholic Health Initiatives Medical Plan—Blue Cross Blue Shield) was prohibited from denying the same or equivalent room and board coverage in behavioral health facilities that it provided in non-behavioral health facilities, overturning the district court’s [Read More]