By KEVIN R. MISEREZ, ESQ.
Wachler & Associates, P.C.

The Department of Health and Human Services recently unveiled the next two steps in its ongoing efforts to reduce the significant volume of claims pending at the Administrative Law Judge (ALJ) level of the Medicare appeals process, each of which involve additional settlement options for providers to resolve their pending claim appeals.

The first new settlement option was announced by the Centers for Medicare & Medicaid Services (CMS), which CMS refers to as the “low volume appeals settlement option (LVA).” As the name suggests, the LVA will be limited to provider appellants with a low volume of claims pending at the ALJ [Read More]

By JESSICA RUSSELL & PAHL ZINN

It is not uncommon for a physician organization to act as an intermediary between its physician participants and third-party payers to facilitate the negotiation and acceptance of reimbursement rates and other payer contract terms.

However, when facilitation becomes negotiation and a PO accepts contracts with third-party payers on behalf of physician participants, also known as “single-signature contracting,” a PO may be unintentionally engaging in illegal “price-fixing” in violation of antitrust law.

Under Section 1 of the Sherman Act, it is illegal to engage in horizontal price fixing arrangements. This includes circumstances where PO physician participants, who are otherwise competitors in the market, collectively agree or [Read More]

The Department of Health and Human Services would be barred from crafting future immunization-related rules, meaning any age- or dose-related updates would need legislative approval, under a pair of bills debated in committee Nov. 30.

HB 5162 and HB 5163 comes as parents with objections to child immunization told the House Oversight Committee how state and local health officials have been “overly zealous” in pursuing a pro-vaccination agenda by belittling those seeking a state exemption.

Joel Dorfman, of Michigan for Vaccine Choice, said DHHS has used the administrative rules process to “eviscerate” a state law that is neutral on child immunizations by treating citizens who don’t want to give their kids shots [Read More]