Chair's Column
by Andrew J. Demetriou, Fulbright & Jaworski LLP, Los Angeles, CA

This month we turn our spotlight on the work of the Payment and Reimbursement Interest Group. As its name implies, the lawyers in this group primarily deal with the intricacies of federal and state healthcare programs. As with virtually all legal regimes affecting healthcare in this country, the governmental payment systems have grown incredibly complex over the past four decades. Prior to the enactment of the Medicare and Medicaid programs in 1965, the role of government in the financing of healthcare was fairly small, and primarily limited to the operation of hospitals and related facilities for identified populations, such as veterans hospitals and public hospitals for the indigent. With the advent of a major purchasing role for the federal government through the Medicare program (and by proxy through its predominant funding of the state-based Medicaid program) came the rise of substantial administrative apparatus to handle the billions of dollars in federal funds now flowing into the hands of healthcare providers. We need to keep in mind that from a relatively modest start--the initial outlays for all Medicare and Medicaid benefits were well under $10 billion in the late 1960s--the federal payments for health benefits now rival defense spending as the largest line item in the federal budget.

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Medicare Launches New Provider Reimbursement Appeal Rules
by John P. Wagner, Nosaman, Sacramento, CA

On May 23, 2008, the Centers for Medicare and Medicaid Services (CMS) promulgated long-awaited new provider reimbursement appeal rules, primarily dealing with appeals of Medicare Part A reimbursement before the Provider Reimbursement Appeals Board (PRRB). The major rule changes were expected -- and the new rules are actually less onerous in some cases than the earlier proposed rules published in 2004. Some of the major aspects are as follows.

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New Medicare Competitive Bidding Program Faces Significant Challenges
by Betty C. Pang and Shilpi Agarwal, Latham & Watkins LLP, San Francisco, CA

Approximately one year after publishing its final rule on the competitive bidding program for selected durable medical equipment, prosthetics, orthotics and supplies ("DMEPOS"), on May 19, 2008, the Centers for Medicare and Medicaid Services ("CMS") published the winning bidders for the first round of the program. The announcement was made in the midst of controversies, giving rise to efforts to either set aside or delay the July 1, 2008 implementation date. Legislators, medical suppliers, Medicare beneficiaries and several special interest groups have raised concerns about the potential outcomes of this new program, including the program's impact on beneficiary access to quality products and the ability to correct procedural flaws in the bid selection process. Despite the raised concerns, Round 2 of the program is already underway, and CMS has set in place a process in anticipation of proceeding with both Rounds 1 and 2 as scheduled.

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Supreme Court's June 19 Decision About The Standard Of Review Applicable To ERISA Cases
by Cynthia Marcotte Stamer, Glast, Phillips & Murray, PC, Dallas, TX

The United States Supreme Court's June 19th decision in Metropolitan Life Insurance Co. v. Glenn clarifies the latest in a series of regulatory and judicial developments concerning the applicable standard of review for courts when reviewing claims decisions made under insured and self-insured managed care or other health insurance plans regulated by the Employee Retirement Income Security Act (ERISA).

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Payment & Reimbursement Interest Group

The Payment & Reimbursement Interest Group follows trends, changes and practices in reimbursement, billing and collection under Medicare, Medicaid and other federal and state healthcare programs.

The IG is led by Chair Karen Ann Lloyd, Community Health Network, Indianapolis, IN and Vice Chairs Angela Lai, Nossaman Guthner Knox & Elliott LLP, Sacramento, CA; René Y. Quashie, Fulbright & Jaworski LLP, Washington, DC; Esther R. Scherb, Latham & Watkins LLP, Washington, DC and Stephen M. Sullivan, Sullivan Stolier & Resor, New Orleans, LA.

If you would like to join the Interest Group, continue by clicking the following link: Health Law Section IG Sign-up Form.

Do you want to communicate your ideas to thousands of other members through the wonders of cyberspace? To contribute a newsletter article on a health law topic, send us your ideas to Adam.Bielawski@americanbar.org