The Final ACO Regulations:
Is Participation Worth a Second Look?

The Health Law Section is offering a two-part webinar series that will take an in-depth look at how the Centers for Medicare & Medicaid Services have changed the Medicare Shared Savings Program (MSSP) through the publication of final regulations. CMS has changed a number of the key provisions of the proposed MSSP rules, which were broadly regarded by the provider community as discouraging participation in the MSSP. 

Tuesday, November 22, 2011
Part 2: Assignment of Beneficiaries, Risk, Structure and Governance, and Tax Issues

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Reimbursement for Emergency and Non-Emergency Services Provided by Out-of-Network Physicians: The Issue of Balance Billing
By Jeffrey Gold, Esq., Danielle Drayer, Esq., and Cara Zucker, M.P.A., Healthcare Association of New York State, Rensselaer, NY

While there has been considerable evolution in health plan and provider relationships in collaborative care models and in federal and state healthcare reform, still significantly unresolved are myriad issues around what constitutes proper compensation for out-of-network physicians performing services, particularly at in-network hospitals, and how to insulate patients from receiving substantial balance bills for seemingly covered services. Federal and state legislation, regulatory oversight, litigation, modifications to network designations by insurers, and creation of a new not-for-profit database out of settlement monies from actions by the New York Attorney General have all attempted to address pieces of this puzzle, but problems have continued to percolate nonetheless.

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The Sixth Circuit Gives Teeth to the Medicare Secondary Payer Act Private Cause of Action
By Kristopher R. Alderman, The Gibson Firm LLC,
Woodstock, GA

In a ruling that should be considered by group health plans (“GHP”s) across the country, the Sixth Circuit recently held that a healthcare provider can impose liability against a GHP for double damages under the Medicare Secondary Payer Act (“MSPA”) when the GHP terminates the coverage of a retiree who became eligible for Medicare due to end stage renal disease (“ESRD”). Significantly, the Sixth Circuit determined that the private cause of action was viable even though the provider did not satisfy the “demonstrated responsibility” provision prior to bringing the claim. This decision in Bio-Medical Applications of Tenn., Inc. v. Cent. States Se. & Sw. Areas Health and Welfare Fund gives private parties the ability to enforce the terms of the MSPA without having to demonstrate that GHPs are responsible for paying for certain services prior to initiating litigation.

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Exclusive Provider Benefit Plans – New for Some, But Not For All
By Monica L. Piñon, Texas Department of Insurance, Austin, TX

In May of 2011, the Texas Legislature passed a bill allowing for the establishment of commercial exclusive provider benefit plans (“EPOs”) as another type of preferred provider benefit plan (here, referred to as a “PPO”) that can be offered to insureds. Similar to a traditional PPO, an EPO consists of a network that carriers can use for the delivery of benefits to insureds. However, what distinguishes an EPO from a traditional PPO is its limitation on providing benefits only for services obtained within the network, and providing no benefits for services voluntarily obtained outside of the EPO network.

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Did you know membership in an interest group is FREE with your Health Law Section membership?

Did you know your membership in the ABA Health Law Section qualifies you for free membership in up to three interest groups of your choice? Interest groups, which are comprised of twelve practices areas within health law, make significant contributions to the Section's programming, publications and legislative initiatives. The interest groups also provide an excellent opportunity for you to interact with and have access to some of the most outstanding lawyers in the legal community. You can enroll on our webpage by clicking here. If you have any questions or need more information, please contact Simeon Carson at simeon.carson@americanbar.org

Managed Care and Insurance Interest Group

The Managed Care & Insurance Interest Group serves as a resource to attorneys who represent or regulate entities and/or individuals doing business in the managed care industry.

The IG is led by Chair Alice L. King, Chair, Towers Watson, Dallas, TX and Vice Chairs Jeffrey Gold, Healthcare Association of NYS, Rensselaer , NY; Denise E. Hanna, Locke Lord Bissell & Liddell, LLP, Washington, DC and Monica Piñon, Texas Department of Insurance, Austin, TX.

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

ABA eSource Editorial Board

The ABA Health eSource Editorial Board is led by Chair Adrienne Dresevic, The Health Law Partners, PC, Southfield, MI and editorial board members Claire Castles, Jones Day, Los Angeles, CA; Michael E. Clark, Duane Morris LLP, Houston, TX; Marla Durben Hirsch, Potomac, MD; Conrad Meyer, Chaffe McCall, LLP, New Orleans, LA; Robert T. Rhoad, Crowell & Moring LLP, Washington, DC and Jennifer Tsao, Hernandez Schaedel & Associates LLP, Pasadena, CA.