Section News


    Feature Friday - Elizabeth Murray - July 20, 2018

    July 19, 2018 12:38 PM by blakleyr

    Welcome to Feature Friday!

    Today we have the super awesome pleasure of introducing you to, Elizabeth Murray.

    Elizabeth Murray BSN, RN, LNCC is an independent legal nurse consultant with and owner of Elizabeth Murray Consulting, LLC a consulting firm in the Northern Virginia/Washington DC area, primarily consulting on defense cases in Long Term Care and Medical Malpractice. Elizabeth is a former US Army officer, and has extensive experience in adult and pediatric Critical Care and Emergency nursing. She has been working in the legal nurse consulting field for fourteen years and currently serves on the board as President Elect of the American Association of Legal Nurse Consultants (AALNC).

    (Elizabeth is pictured in both photos with her beautiful family.)

    Q: Why Healthcare?

    Elizabeth: Even before I earned my BSN, I was a nurse at heart. My entire life I have been interested in biology and pathophysiology, and making compassionate connections with those around me. Nursing was a natural fit. And, as soon as I understand a medical concept, I want to teach it. The collegial atmosphere of a teaching hospital is where I feel most comfortable.

    Q: Why work in the legal field?

    Elizabeth: Education is the crux of nursing. Working in the legal field is the pinnacle of patient advocacy. Legal Nurse Consultants are uniquely able to bring about change that protects patients and improve patient care by educating about the standards of care, medical research, and management of risk. Defense of doctors, nurses, and other healthcare professionals is a passion of mine because in my experience most practitioners are making educated decisions that they believe are best for the patient at that time. On the flip side, my clients know that I am the first one to tell them if something was truly negligent or outside of the standard of care. Every case has its own distinctive and individual facts, and every day is a new adventure.

    Q: What is one piece of advice that was given to you and has stuck with you?

    Elizabeth: A professor at my alma mater, Seattle University, once told me that every minute with a patient is a teaching moment and that every intake interview question about tobacco use is an opportunity. A study of tobacco users revealed that a large percentage stated their healthcare providers had never told them to stop using tobacco. The doctor or nurse would ask how much the patient smoked per day, and write it down, and move on to another part of the exam. Smokers took that as an implicit approval of their smoking. I make sure I tell every patient who reports tobacco use, officially, to stop smoking.

    Q: What is one surprising fact about you?

    Elizabeth: I was an officer in the Army and served in the Army Nurse Corps. I found the collaboration in a military hospital empowering, and am humbled and honored to have served with so many brilliant healthcare professionals at the start of my career. Within a few months of graduating from nursing school, I was a charge nurse on the Army’s largest Medical Surgical floor. The lessons I learned in leadership, teamwork, and professionalism have served me well.

    Q: How do you define success?

    Elizabeth: I define success as achieving balance. Right now, I have my dream job owning my consulting business, enjoy going to my kid’s lacrosse games and swim meets, and volunteer in ABA and AALNC with some of the most dynamic and interesting people. If only I had five more hours in each day!

    Q: What are three things you have already done on your bucket list?

    Elizabeth: I shared a glass of red wine with Dario “The Butcher” Cecchini in Panzano Italy from his private stash.
    My family went snorkeling and explored an old, crashed, cartel plane in the sea near Cartagena, Colombia.
    I lived in a haunted house on Fort McNair in DC that was formerly the courthouse where the U.S. tried John Wilkes Booth and his conspirators. The week we moved in, an A&E Haunted House show aired about Mary Surratt’s hauntings of my house, and twice a day a haunted house bus tour stopped in front.

    Q: Have you ever been in awe of anything? If so, what?

    Elizabeth: My colleagues in Critical Care are generally all awesome, however, my fellow nurses in the Pediatric Intensive Care Unit (PICU) have left me in awe time and time again. Nurses who care every day for the smallest and most vulnerable of us are some of the most excellent human beings I have ever met. I was a nervous wreck working with intubated infants, and the experienced PICU nurses were unflappable, gentle, kind, and astute.

    Q: If you could live in a fictional land, what would it be and why?

    Elizabeth: I always thought the Twilight Zone “Bewitchin’ Pool” episode where kids dive into their swimming pool only to come up in a pristine river bank where children are playing, and a grandmother type serves cake all day seemed like a pretty great place.

    Q: How does the Health Law Section impact you?

    Elizabeth: I came to the ABA Health Law Section several years ago as a liaison from my professional association, the American Association of Legal Nurse Consultants (AALNC). In that time, I have found a home in this organization filled with energetic and intelligent attorneys, experts in their fields and yet continually searching to learn more. In every golden nugget I learn at the Washington Health Summit, or the Annual Emerging Issues in Healthcare Law Conference I find new niches to help attorneys expand their knowledge of the inner workings of healthcare, and take back new issues to my nurse colleagues to digest.

    Q: Tell us about one of your proudest moments.

    Elizabeth: My grandfather, Ted Cox, was the commander of “Fox Company” 291st Infantry Regiment in World War II in Europe. The surviving members of their group had a reunion every year to visit and discuss battles they fought. My grandfather published a book about his experiences when he was in his early 90’s called, “The Men of Fox Company.” He was never afraid to take on something new. One of my proudest moments was meeting him on the Mall in DC when he took an Honor Flight with other veterans to see the new World War II Memorial. It was an honor to see he and the other men arrive and tour the memorial, finally receiving the recognition their bravery deserved. My kids were small, but they understood the importance of the monument, and that actions their great-grandfather took improved freedoms around the world.

    Q: What do you like about being part of the Health Law Section?

    Elizabeth: I love the connections I have made with so many different individuals, and especially learning how each member of the Nursing & Allied Healthcare Professionals Task Force came to our group. Every member brings a unique story and background, and passion for Health Law. I have especially enjoyed working with our law students and young lawyers on writing projects they hope to publish with the ABA.


    We would love to give a huge shout-out to Elizabeth and thank her for participating in this week’s Feature Friday! Get to know your fellow HLS members and leaders by stopping by every Friday to check out a new feature. #FridaysAreForLawyers

    If you are interested in being featured, please contact me at, Rachel.blakley@americanbar.org. All members are encouraged to participate!!!

    Missouri Flooded with Opioids 2012-2017

    July 19, 2018 12:02 PM by billupsj

    A new Minority Staff Report from the US Senate Committee on Homeland Security and Governmental Affairs, found that three companies shipped approximately 1.6 billion doses of prescription opioids to Missouri pharmacies from 2012 to 2017. “It’s staggering. Over six years we averaged 260 pills for every man, woman, and child in Missouri,” Senator Claire McCaskill said when the report was released. “The opioid crisis these pills have fueled is a failure of policy and oversight by the government and a failure of basic human morality on the part of many pharmaceutical companies and distributors—a failure that has destroyed families and communities all over our state.”

    Uttam Dhillon New Head of DEA

    July 19, 2018 12:00 PM by billupsj

    White House lawyer Uttam Dhillon has been named the new head of the DEA. He most recently served as deputy White House counsel and is replacing Robert Patterson. Dhillon was confirmed by the Senate in 2006 as the first Director of the Office of Counternarcotics Enforcement at the Department of Homeland Security (DHS). In that role, Dhillon served as the primary policy advisor on counternarcotics issues, focused on combating the connections between illegal drug trafficking and terrorism and developed regional counternarcotics strategies for DHS.

    MA Supreme Court Allows Judges To Require Sobriety

    July 19, 2018 11:59 AM by billupsj

    The Massachusetts Supreme Judicial Court ruled that a person with a substance use disorder may be jailed for relapsing while on probation. The unanimous ruling found that judges, while they should consider the challenges of drug addiction, “must have the authority to detain a defendant” who has violated probation by using drugs.

    The defendant contended that the court had violated her constitutional rights by ordering her to remain drug-free because her substance use disorder made it “virtually impossible” for her to abstain through sheer will.  The Massachusetts Medical Society, the American Academy of Addiction Psychiatry, and dozens of doctors filed briefs in support of her argument. In her complaint, she cited findings by the Surgeon General that addiction drastically reduces one’s ability to make decisions about drug use.


    GAO Evaluates VHA's Response to 2016 Report

    July 19, 2018 11:57 AM by billupsj

    In 2017, GAO released a report that examined the VHA physician staffing and retention data. Primarily, GAO found issues with VHA's ability to account for how many physicians and physician trainees it employed. Recently, GAO completed a follow-up report regarding VHA's response to its recommendations for improvement. Since the 2017 report, VHA has implemented a new human resource database, HR Smart, that can track each position at VA medical centers. Additionally, VHA has used various strategies to improve recruitment and retention, like financial incentives and physician training programs. However, VHA has not provided an evaluation to gauge the effectiveness of these efforts.

    Departments Clarify "Greatest-of-Three" Regulation After Legal Challenge From ACEP

    July 19, 2018 11:49 AM by billupsj

    On May 3, 2018, the U.S. Departments of Labor, HHS, and the Treasury clarified the ACA’s “greatest-of-three” regulation (“GOT regulation”) in response to an entry of summary judgment against the Departments in American College of Emergency Physicians (ACEP) v. Price. The GOT requires payors to pay out-of-network emergency service providers the greatest-of-three payment amounts: (1) the in-network amount; (2) the usual, customary, and reasonable (“UCR”) amount; or (3) the Medicare rate (45 C.F.R. § 147.138(b)(3)). According to ACEP, the GOT regulation was substantively flawed because it failed to guarantee a reasonable rate and procedurally flawed because the Departments failed to respond to their concerns during the public comment period. The District Court for the District of Columbia agreed on the procedural element and remanded to the Departments for further comment, which was published in the Federal Register on May 3, 2018. In the clarified commentary, the Departments put to rest the possibility of a national database for determining UCR amounts. They further clarified that the GOT regulation sets the floor for reimbursement, not a ceiling. The parties stipulated to dismissal and the case was dismissed on May 23, 2018. The GOT Regulation remains in effect for the foreseeable future.


    Missouri Physician Pleads Guilty to Obstructing Investigation

    July 19, 2018 11:47 AM by billupsj

    Dr. Vidal Sheen, a Missouri physician, pled guilty to charges of obstructing an FBI investigation.  Dr. Sheen was under investigation regarding claims that he billed for “face to face” office visits using false templates, on dates when he was outside of Missouri and in some instances, outside of the United States. When Dr. Vidal received a subpoena for his records, he supplied investigators with documents that contained false entries. Sentencing is set for October with a maximum sentence of twenty years in prison and fines of up to $250,000 per count. 

    DOJ Announces $1.5 Million Settlement with a Florida HHA and Owners

    July 19, 2018 11:46 AM by billupsj

    On July 16, 2018, the DOJ announced a $1.5 million settlement with Healthquest, Inc., a home health care company in Florida, and its owners, Frank and Ruth Jaramillo, to resolve allegations that from December 2013 to May 2017, Healthquest paid kickbacks to marketers in order to induce patient referrals.  In addition to paying the civil monetary penalty, Healthquest agreed to enter into a CIA which requires Healthquest, for five years, to engage an independent review organization to conduct system and transaction reviews. The DOJ investigation stemmed from a whistleblower complaint from a former Healthquest marketer, who will receive $300,000 as part of the settlement.

    Cleveland Clinic and Luye Medical Partner in China

    July 19, 2018 11:42 AM by billupsj

    Cleveland Clinic and Luye Medical Group have partnered in a strategic collaboration to bring value-based care to Shanghai New Hong Qiao International Medical Center.  Luye Medical is the first member of the Cleveland Clinic Connected international program and is the regional healthcare services arm of Luye Life Sciences Group.  Cleveland Clinic Connected introduces hospitals to Cleveland Clinic’s best practices, technology, and clinical expertise, and the parties hope to foster key specialties, including cardiology, urology, and oncology, and innovation in support of the Shanghai government’s Healthy Shanghai 2030 initiative. 

    Lakeland Health and Spectrum Health Consider Affiliation

    July 19, 2018 11:41 AM by billupsj

    On July 11, Lakeland Health and Spectrum Health revealed plans to integrate.  The Boards of Directors for the organizations announced they will be pursuing a definitive agreement with expectations to be finalized by October 1, 2018.  Lakeland Health, a three-hospital system in southwestern Michigan employing more than 4,000 persons with over 450 providers, will become a division of Spectrum Health under the proposed arrangement. 

    Research Shows No Benefits of Cannabis for Chronic Pain

    July 12, 2018 11:48 AM by billupsj

    Cannabis use shows no medical benefit for chronic pain according to a published major study. The study is one of the largest and most in depth on the drug’s medical use.  Its results show that cannabis did not cut pain or help sufferers replace opioids.

    Peer Support on Campus

    July 12, 2018 11:46 AM by billupsj

    A landmark study of more than 1,100 students at 12 colleges, published in The Journal of the American Academy of Child & Adolescent Psychiatry, found that Active Minds, a student peer organization focused on increasing mental health awareness, decreasing stigma, and affecting mental health knowledge, attitudes, and behaviors, has a significant impact on student health and well-being. The organization creates a positive and supportive climate for mental health on college campuses. Student peer organizations’ activities can complement more traditional programs and play an important role in improving the campus climate with respect to mental health.

    Is Illegal Drug Use Child Abuse?

    July 12, 2018 11:44 AM by billupsj

    The Pennsylvania Supreme Court is considering a case that asks if illegal drug use qualifies as child abuse. A friend of the court brief urged the court to decide that women who used drugs during pregnancy should not be punished. “In several states, a single positive drug test is not just the basis for labeling a mother as a child abuser, it is also grounds for removing a child from its mother.” Twenty-four states and the District of Columbia have passed laws classifying substance use during pregnancy as child abuse under child-welfare laws.

    CMS Proposes Rule Change to Protect Medicaid Provider Payments

    July 12, 2018 11:43 AM by billupsj

    On June 10, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Medicaid Provider Reassignment regulation that would eliminate a state’s ability to divert Medicaid payments away from providers, with the exception of payment arrangements explicitly authorized by statute. 

    Suicide Rates Among Veterans Remains Constant

    July 12, 2018 11:41 AM by billupsj

    Recently, VA released findings from the most recent VA National Suicide Data Report. The report analyzed suicide mortality among U.S. veterans from 2005-2015. The study reflects consistent suicide rates among veterans between 2014 and 2015. In 2015, veterans accounted for 14.3% of all deaths by suicide among U.S. adults, while representing only 8.3% of the U.S. adult population. Notably, in 2015, suicide among veterans was 2.1% higher when compared with non-veterans, and an average of 20.6 veterans died by suicide each day.


    CMS Announces Demonstration to Accept Medicare Advantage Contracts for MACRA

    July 12, 2018 11:38 AM by billupsj

    CMS announced on June 29 they intend to accept Medicare Advantage risk based contracts as an alternative payment model under MACRA.  Physician groups have criticized their inability to receive credit under MACRA for their risk based Medicare Advantage contracts. CMS is considering the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration to “test whether exempting, through the use of waiver authority, clinicians who participate to a sufficient degree in certain payment arrangements with Medicare Advantage Organizations (MAOs) (combined with participation, if any, in Advanced Alternative Payment Models (APMs) with Medicare Fee-for-Service (FFS)) from the Merit-based Incentive Payment System(MIPS) reporting requirements and payment adjustment will increase or maintain participation in payment arrangements with MAOs similar to Advanced APMs and change the manner in which clinicians deliver care.”  CMS hopes to launch the demonstration later this year.


    DOJ Announces $14.7 Million FCA Settlement with Health Quest and Putnam Health Center

    July 12, 2018 11:36 AM by billupsj

    On July 9, 2018, the DOJ announced that Health Quest Systems, Inc., an integrated network of hospitals and healthcare providers that deliver surgical, medical and home health care services based in New York, and Putnam Health Center, a Health Quest subsidiary hospital in New York, agreed to pay over $14.7 million and enter a CIA to resolve FCA allegations. Health Quest allegedly did not sufficiently document evaluation and management services, resulting in billing services that were two levels higher than supported by the medical record, and submitted claims for home health services that lacked sufficient medical records to support the claim, including documentation of a face-to-face encounter with a physician.  Additionally, Putnam Health Center allegedly violated the Stark Law by submitting claims for inpatient and outpatient services referred by two orthopedic physicians who had direct financial relationships with the hospital. The physicians allegedly received compensation that exceeded fair market value from the hospital for providing administrative services. This settlement resolves three FCA qui tam lawsuits brought by former employees of Health Quest who will receive in excess of $2.8 million collectively.

    OIG Releases Report on Improperly Paid Medicare Claims for Chiropractor-Ordered Items and Services

    July 12, 2018 11:33 AM by billupsj

    On July 10, 2018, the OIG released a report titled, “Medicare Improperly Paid Providers for Items and Services Ordered by Chiropractors,” which found that Medicare payments for chiropractor-ordered items and services did not comply with federal requirements.  Specifically, the OIG discovered $6.7 million in Medicare payments for imaging services, clinical laboratory services, durable medical equipment, prosthetics, orthotics, medical supplies, and home health agency services that were ordered by chiropractors from 2013 – 2016 and were improperly paid. The vast majority of the improper claims were for items and services that were billed before January 2014 when CMS began using claim processing edits to deny these types of claims. Pursuant to the OIG’s suggestion, CMS will start recoupment of the identified overpayments and instruct MACs to notify providers of potential overpayments so that those providers can exercise reasonable diligence to investigate and return any identified similar overpayments.

    601 Individuals Charged; Allegedly Responsible for Over $2 Billion in Healthcare Fraud Losses

    July 12, 2018 11:31 AM by billupsj

    On June 28th, US AG Jeff Sessions and HHS Secretary Alex M. Azar III, announced a massive national takedown.  In what is asserted to be the largest ever health care fraud enforcement action, 601 defendants were charged in 58 federal districts. These individuals were responsible for more than $2 billion in false billings according to the charges. Included in the enforcement action were 162 defendants, including 76 doctors, who have been charged for their roles in prescribing and distributing opioids and other dangerous narcotics.

    CMS Puts $10.4 Billion in ACA Risk Adjustment Payments on Hold

    July 12, 2018 11:30 AM by billupsj

    The Trump Administration announced on July 7, 2018, that it had frozen CMS risk adjustment payments that were required under the ACA. 

    Citing a February 2018 ruling from the US District Court in New Mexico, ruling  for the District of New Mexico, which invalidated CMS’ use of the statewide average premium in the risk adjustment transfer formula, the Administration has mandated that CMS not make risk adjustment payments to insurers for 2017. According to the court in New Mexico Health Connections v. United States Department of Health and Human Services et al., the use of statewide average premiums in its risk adjustment methodology is “not contrary to law, but is arbitrary and capricious.” Notably, this holding is contrary to the recent US District Court case in Massachusetts, Minuteman Health, Inc. v. United States Department of Health and Human Services et al. In that case, the court stated that CMS’ operation of the risk adjustment payment program was not arbitrary and capricious and instead was reasonable given the need for competition in health insurance markets

    The risk adjustment payments have been an integral piece of the ACA and have, among other items, ensured the stability of the individual health insurance market. According to CMS, for the 2017 benefit year, the calculated risk adjustment transfer amounts for the 2017 benefit year are $10.4 billion. This figure includes transfers across catastrophic, small group, and individual non-catastrophic risk pools. Though halting these payments may be temporary in nature, as CMS said it has asked the court to reconsider its ruling, there is currently no clear timeline as to when the agency would again provide payments. CMS added in its press release that it will soon provide additional guidance on risk adjustment payment issues for insurers.


    Humana Acquires Kindred Healthcare and Stake in Kindred at Home

    July 12, 2018 11:28 AM by billupsj

    Health insurer Humana, in conjunction with the two private equity firms TPG Capital (TPG) and Welsh, Carson, Anderson & Stowe (WCAS), completed the acquisition of long-term care and rehabilitation provider Kindred Healthcare, Inc. According to the terms of the transaction, Kindred consolidated its long-term acute care, inpatient rehabilitation, and contract rehabilitation business units under the name Kindred Healthcare, and these operations were separated from the home health, hospice, and community care divisions now collectively referred to as Kindred at Home. Kindred Healthcare will function as a separate entity owned by the TPG and WCAS, and Kindred at Home will operate under 40 percent ownership by Humana and 60 percent ownership by the two private equity firms.  Humana retains a right to buy the remaining ownership interest in Kindred at Home through a put/call arrangement.

    Allegheny Health Network Identifies Location for Fourth Micro-Hospital

    July 12, 2018 11:27 AM by billupsj

    Allegheny Health Network (AHN) has settled on a location for its fourth of four planned neighborhood hospitals to be opened in the Pittsburgh area in the next two years. These facilities offer the community 24-hour access to an emergency department, 10 inpatient beds, diagnostic care, and various other services. Spearheading a new approach to patient-centered medicine, these hospitals aim to improve access for individuals in need of both short-term inpatient and outpatient care and are part of AHN’s. planned $1 billion investment strategy to improve access to affordable care in the western Pennsylvania region.

    Cerner and Lumeris Developing New EHR to Facilitate Value-Based Care

    July 12, 2018 11:25 AM by billupsj

    Cerner Corporation, a global leader in health care technology, and Lumeris Health Outcomes, a health plan and value-based care managed services operator, announced a strategic relationship to develop a new EHR system, Maestro Advantage, designed to reduce costs and boost patient outcomes for providers participating in value-based payment relationships.  As part of the arrangement, Cerner Capital, Inc., a subsidiary of Cerner, entered into a $266 million stock purchase agreement to acquire a minority interest in Essence Group Holdings, an affiliate of Lumeris.  According to Cerner, Maestro Advantage “uniquely integrates actionable data and insights with provider workflows, leveraging existing investment in digitized data and processes. Maestro Advantage is designed so providers can more effectively assess risk and create interventions and better maximize outcomes for patients enrolled in value-based arrangements, such as PSHPs and MA plans. Maestro Advantage will manage health systems’ increasingly complex mix of owned- and affiliated-provider relationships across any EHR in the network.”

    Feature Friday - Kirk Nahra - July 13, 2018

    July 12, 2018 9:29 AM by blakleyr

    Welcome to Feature Friday!

    Today we have the very great pleasure of introducing you to Kirk Nahra. We are very grateful that Kirk has decided to participate in this week's Feature Friday.

    Kirk Nahra is a partner with Wiley Rein LLP in Washington, D.C., where he specializes in privacy and information security litigation and counseling, along with a variety of health care and compliance issues. He is chair of the firm’s Privacy Practice and co-chair of its Health Care Practice.  He assists companies in a wide range of industries in analyzing and implementing the requirements of privacy and security laws across the country and internationally.  He provides advice on data breaches, enforcement actions, contract negotiations, business strategy, research and de-identification issues and privacy, data security and cybersecurity compliance.

    A long-time member of the Board of Directors of the International Association of Privacy Professionals, he served for many years as the editor of Privacy Advisor, the monthly IAPP newsletter, and is a founding Board Member of the Privacy Bar Section of the IAPP. He regularly speaks before a broad variety of audiences, including lawyers, nonlawyers, privacy and data security personnel, medical professionals and others, on topics including privacy, data security, cybersecurity, and overall healthcare issues.  He teaches Health Care Privacy and Security and The Law of Information Privacy at the Washington College of Law at American University.  He also serves on the adjunct faculty at Case Western Reserve University Law School and the University of Maine Law School.  He received his law degree from Harvard Law School and undergraduate degree from Georgetown University.  He is married to Margit Hunt Nahra (a retired health lawyer) and has two children, Joe (age 23 and a recent graduate of the University of Pennsylvania) and Alia (20), a junior at Washington University in St. Louis.

    (Kirk is pictured on the top with his wife, son, and daughter. In the bottom photo, he is pictured with his brother at the US Open.)


    Q: What do you like most about being a lawyer?

    Kirk: I love the problem-solving part of what I do – taking a business situation or other problem, and helping my client work through their choices and how best to act in the specific situation.

    Q: Why health law?

    Kirk: I’ve been in one job my entire career, but I have to say that I have basically stumbled into all substantive aspects of my career.  I got into health law through an odd back door having to do with insurance fraud investigations.  That led me to health care fraud, and then health care compliance and then ultimately to health care privacy and security and a broad range of Health IT activities.  Advice for law students – be ready to take advantage of opportunities that present themselves.

    Q: What is one piece of advice that was given to you and has stuck with you?

    Kirk: It really wasn’t advice, but a lesson.  As a young associate, I had briefed an older associate on a new project, where we were new to an area and meeting with lots of older and more experienced attorneys.  The older associate exhausted everything I had told him (which meant everything he knew) about ten minutes into the meeting we were hosting, and then over the rest of the meeting, just confidently described and dealt with everything else.  That sense of confidence – and what that can do and where you need to be careful with it - has been a big lesson for me in my career.  It’s important to know things – but it can also be just as important to sound like you know things (but you also have to be careful about people bluffing you in that way). 

    Q: What is one surprising fact about you?

    Kirk: I have the largest collection of Pez dispensers that you have ever seen.  I haven’t done a survey, but probably the largest of any section member.  I’m also a really good tennis player.

    Q: If you could give your 16-year-old self some advice, what would you say?

    Kirk: Don’t be afraid of public speaking – it is something that even a terrified teenager can get good at.  Make sure to stay involved in your various communities – your college, law school, neighborhoods, etc. Stay in touch with your friends, even if it is a bit hard.  And learn how to cook.

    Q: How do you define success?

    Kirk: Professional success – which clearly is only one kind of success – involves being well thought of in your work and the ability to control your own destiny to a large extent.  Personal success involves family and interests – raising good kids, staying involved in activities, having interests.

    Q: What are three things on your bucket list?

    Kirk: Wimbledon. Teaching at Georgetown and Harvard (my alma maters).  Teaching my future grandchildren to play tennis.

    Q: If you could travel in time, forward or backward, where would you go and why?

    Kirk: These days, I would like to go forward in time 5 or ten years and make sure our country is still ok.

    Q: How does the Health Law Section impact you?

    Kirk: The Health Law Section was the first professional group I got involved in and has been my longest-term activity as a lawyer.  I’ve stayed with it through a variety of changes in my professional life and its always been a great resource with wonderful people.

    Q: Tell us about one of your proudest moments.

    Kirk: When I was younger (and really all through law school), I was terrified of public speaking.  As a young associate, I was asked to give a speech to a decent size audience, and I managed to get through it without throwing up.  Now I give speeches all the time, all over the country, and almost never throw up.  One of my favorite compliments is when people come up to me after a speech and say “I enjoyed that – you don’t sound like a lawyer.”  Or when a student came up to me after a class session to say “I expected to hate this but you made it enjoyable.”

    More recently, I’m really proud of my work mentoring younger people – ranging from young college students to law students to a variety of young professionals, through formal and informal programs.  As I’ve gotten older, I find that there’s a lot I can contribute that is useful to a lot of people.


    We greatly appreciate Kirk Nahra for participating in this week’s Feature Friday. Kirk, we would like to thank you for everything that you do for the Section and the Health Law field. You are awesome!

    If you would like to participate in Feature Friday, please email me at rachel.blakley@americanbar.org. All HLS are welcome to participate. #FridaysAreForLawyers


    Feature Friday - Alexandria Hien McCombs - July 6, 2018

    July 5, 2018 4:52 PM by blakleyr

    Welcome to Feature Friday!

    Today we are very excited to present our ABA HLS Chair-Elect, Alexandria Hien McCombs.

    A thought leader and innovator in the health care industry for nearly 20 years, Alexandria McCombs draws from her diverse expertise in the physician group, hospital, health plan, and management services organization (MSO) settings. She is currently the Assistant General Counsel for Humana responsible for growing the organization’s clinical service and care delivery operations in primary care, home health, telemedicine, and population health management. Her portfolio includes corporate and clinical governance, strategic M & A, value-based arrangements, payor and vendor contracting, national MSO expansion, regulatory compliance, privacy and security, corporate practice of medicine, licensure and scope of practice, governmental investigations, and matters relating to the Medicare, Medicaid, and Commercial lines of business. Alexandria previously served as Vice President and General Counsel for Pinnacle Partners In Medicine where she established the company’s first legal department, restructured the risk management and compliance departments, and supported a 40% growth in revenues through expansion and acquisition. Prior to Pinnacle, she served as Senior Associate General Counsel at Baylor Scott & White Health. Her focus areas included corporate governance, contracts, medical staff credentialing and peer review, and operational, business, and regulatory matters. Alexandria launched her legal career at Haynes and Boone, LLP where she represented public and private companies in M & A and start-up companies in venture capital financing.

    Alexandria earned her law degree from Southern Methodist University Dedman School of Law and graduated cum laude and with Distinction in History from The Colorado College. She minored in French and studied Italian and Renaissance art in Florence, Italy. Alexandria is a member of the Phi Beta Kappa, Pi Gamma Mu, Alpha Lambda Delta and Phi Delta Phi honor societies. Alexandria is fluent in French and conversant in Vietnamese and Italian. 

    As avid runners, Alexandria and her husband compete and volunteer in races ranging from 5Ks to half marathons with their three young children. Alexandria is a Well-being Council ambassador for Humana.

    (Alexandria is pictured with her beautiful family. ***FYI, Alexandria is the mother of the world's greatest superheroes! Also, don't mess with Texas!***)

    Q: What do you like most about being a lawyer?

    Alexandria: I love the creativity and problem-solving powers of being a lawyer. The law provides a canvas while the lawyer brings perspective, depth, and color to a particular issue.

    Q: Why health law?

    Alexandria: Health law is dynamic. There are numerous sub-specialties within health law to focus on and opportunities to make a difference. Whether your client is a physician, hospital, health plan, or other key player in the industry, issues such as data use, quality care, access, and cost affect all of us as consumers.

    Q: What is one piece of advice that was given to you and has stuck with you?

    Alexandria: Believe in yourself. I credit the mentors and sponsors throughout my academic and professional development with believing in my potential even before I did.

    Q: Have you ever been in awe of anything? If so, what?

    Alexandria: I am in awe of athletes who overcome physical and mental limitations to accomplish their goals. From the ultra-marathoner to the Olympian to the 99-year-old runner completing a 5K with a cane, their sport is only limited by their imagination.  

    Q: What is one thing that people probably don’t know about you?

    Alexandria: Chocolate chip cookies are my Kryptonite. In a former role, my Compliance Officer pleased and tormented me by delivering a tray of chocolate chip cookies leftover from a meeting. There were no leftovers from these leftovers.

    Q: How do you define success?

    Alexandria: The best definition of success is giving something 100%. You will not win first place in every race, but you will have no regrets about your effort.

    Q: If you could travel in time, forward or backward, where would you go and why?

    Alexandria: I would travel to a future date like 2050. I’m curious about future advancements in technology, AI, health care delivery, environmental conditions, and development of my children into responsible adults.

    Q: If you were stuck on a desert island and could have 3 things with you, what would those 3 things be?

    Alexandria: I would take a phone, sunscreen thanks to Joyce Hall’s wise reminder, and a Trojan horse. The Trojan horse would be filled with my family members, food, books, and necessities to transform the desert island into a comfortable retreat.

    Q: What is one of your most embarrassing moments?

    Alexandria: In wrapping up a positive job interview with a company’s CEO, the CEO stepped away from the conference table and presented me with his favorite book on leadership. I glanced at the title and summary and placed the book on the table. Was he showing me the book for illustrative purposes or giving me the book? With three seconds to deliberate, I opted to “forget” the book than to risk the embarrassment of the CEO asking me to return his book. As soon as I approached the door, he extended the book to me. I later received and accepted the job offer.  

    Q: Tell us three things that are on your bucket list.

    Alexandria: I would like to run a full marathon, take dancing lessons with my husband, and travel to every state in America.

    Q: What fictional world or place would you like to visit?

    Alexandria: I would like to visit Genovia in the Princess Diaries and sing with Julie Andrews and hang out with Anne Hathaway.

    Q: What did you want to be when you were little?

    Alexandria: I wanted to be a pediatrician. As a toddler refugee escaping from the fall of Saigon, my family was sponsored by an Episcopal and Lutheran church in Lewisburg, PA in the fall of 1975. I contracted a viral infection that prevented me from walking for several weeks. The pediatrician treating me in the local hospital became my hero. He did so with respect and grace to a refugee family that could only repay him with gratitude and egg rolls.

    Q: What does being a part of the ABA Health Law Section mean to you?

    Alexandria: The ABA Health Law Section—as our outstanding Chair Hilary Young described—is a community. It is a community of health lawyers and professionals coming together to share ideas, engage in healthy debate, and offer ways to improve the legal profession and health policy. The Health Law Section is also a second family to me with wonderful colleagues and friends.


    Huge shout out to Alexandria for graciously agreeing to participate in this week’s Feature Friday! We very much appreciate everything you do for the Section and look forward to you being the Section's Chair in this upcoming Bar year. Thanks!!!!

    Make sure to check back every week to get to know more about your fellow HLS member and leaders. #FridaysAreForLawyers

    Are you interested in participating in Feature Friday? If so, email me at rachel.blakley@americanbar.org. All HLS members are welcome to participate!!! 

    Feature Friday June 1, 2018

    May 31, 2018 5:09 PM by blakleyr


    Welcome to Feature Friday

    Today for Feature Friday, we are beyond pleased to present the man of many degrees and former Section Council Chair, Mr. Paul R. DeMuro, CHC, FHFMA, FACMPE, CPA, MBA, MBI, JD, PhD.

    Paul R. DeMuro is Of Counsel in the Fort Lauderdale office of Broad and Cassel LLP and a voluntary Associate Professor of Public Health Sciences at the University of Miami Miller School of Medicine.  Previously a partner at several prominent law firms, including Latham & Watkins, Paul's passion is the cost-effective delivery of quality health care using data analytics. 

    Paul is a member of the American Institute of Certified Public Accountants, the American Medical Informatics Association, the Medical Group Management Association (where he is both Certified and a Fellow of the American College of Medical Practice Executives), the Healthcare Financial Management Association (where he is a Fellow and a former member of the National Board and its Executive Committee and Past President of the Northern California Chapter), the Healthcare Compliance Association (where he is Certified in Healthcare Compliance), the American College of Healthcare Executives, and the American Health Lawyers Association (where he is both a Fellow and a former Vice Chair of the ACO Task Force), the American Bar Association (where he is a Fellow of the American Bar Foundation, and former Chair of both the Health Law Section and the Joint Committee on Employee Benefits).

    He holds a bachelor's degree, summa cum laude, in Economics from the University of Maryland, is a Certified Public Accountant, with an MBA (Finance) from the Haas School of Business of the University of California, Berkeley.  He holds a Juris Doctorate from Washington University in St. Louis, and a Master and PhD in Biomedical Informatics from the Oregon Health & Science University School of Medicine, where he was a National Library of Medicine post-doctoral fellow, and studied the healthcare systems of many countries.

    He has authored or co-authored over 175 publications and has delivered over 400 presentations throughout the world.

    Now, ladies and gentleman, please put your hands together for Paul!

    (Paul says, "These girls are now 25 (living in NYC, working as a Management Consultant in Data Analytics), 22 (living in Chicago, working as an Investment Banker), and 20 (a computer science major at Harvey Mudd College and a Legal Studies major at Claremont McKenna College in So. Cal., interning this summer for both a health information technology company and a congressional candidate.)" Clearly the apple doesn't fall far from the tree in this family. **Editor cues song, "All I Do is Win.")


    Q: What do you like most about being a lawyer? 

    Paul: The Attorney Client Privilege

    Q: Why health law? 

    Paul: I started in corporate, transferred to litigation, and what I liked most about each was health law

    Q: What is one piece of advice that was given to you and has stuck with you? 

    Paul: Never stop learning and striving to be a better person.

    Q: How do you define success? 

    Paul: If my three daughters are happy, successful, and productive members of society.

    Q: What did you like most about being a Section Chair?

    Paul: Being able to make a difference in diversity. I was able to add a Vice-Chair to the interest groups which did not have a culturally diverse Vice-Chair and have them appoint one.  I also was able to reject those programs which did not have, in my opinion, enough women or culturally diverse individuals on them.

    Q: What is your favorite quote? 

    Paul: Enjoy every day.  It may be your last.

    Q: If you were stuck on a desert island and could have 3 things with you, what would those 3 things be?  

    Paul: a deep water well with unlimited fresh water; a solar generator; and access to satellite internet

    Q: If you could uninvent one thing, considering the implications of uninventing it, what would it be?

    Paul: I would uninvent the cigarette.  It has caused countless harm around the world.  We would all be better off without it. Less people would be ill and our healthcare costs would be lower.

    Q: If you could pick up a new skill in an instant, what would it be?

    Paul: Be proficient in Python coding

    Q: Tell us three things that are on your bucket list. 

    Paul: Develop an educational program that ensures that people can critically analyze data to help fill the over one million jobs requiring this skill, thus lifting up many members in society; become certified as an airline transport pilot (ATP); become a resident of the Grand Cayman

    Q: What did you want to be when you were little? 

    Paul: An actor

    Q: What was your first job? 

    Paul: Clerk typist at a GEICO insurance agency. (I do not think GEICO even has insurance agencies today.)

    Q: You recently went to Cuba. What was that like for you? What were some main takeaways?

    Paul: My impression of Cuba is that someone broke a clock, but time also stopped.  I was told that Cuba had developed a good preventive care system with little money.  I was aghast at what little healthcare Cubans really have access to, e.g., no screening for colorectal cancer unless one is symptomatic, no screening for breast cancer until a woman is 55, no shock trauma units, and a paucity of high tech equipment.  There is very little access to the internet for clinicians, let alone the population. (I could only use the internet in the hotel lobby when it was working.)  Although Cubans have the right to health protection and care, it is only what little care that is available that they have access to.  On the positive side, the physicians who are paid very little seem, to know their patient population and take an interest in health.  There are significantly more physicians than attorneys. My favorite moment was when a member of the delegation who advised me at the start that she was a socialist, later told me at the end of the trip that she had changed her mind about socialism.

    Q: What is one of your most embarrassing moments?

    Paul: One of my most embarrassing moments was as a new associate at the Ober Grimes & Shriver firm in Baltimore, which became Ober | Kaler, which is now part of Baker Donelson.  We had a cocktail reception before starting.  For some reasons, the drinks were in plastic glasses.  I was so nervous that I clutched mine too hard and it cracked, spilling my drink all over. Thankfully, this was not a summer associate position, as I might not have received an offer.

    Q: Why do you attend PLI and what do you like about it?

    Paul: I am attending my first PLI next week and am very much looking forward to it.  It seems to bring together physicians and attorneys, consultants and advisors in a collaborative atmosphere and addresses cutting edge issues.

    Q: What is your favorite thing about the ABA Health Law Section? 

    Paul: The people


    The Section would like to thank Paul for graciously participating in Feature Friday. We very much appreciate your support for the Health Law Section and your betterment of the health law field.

    Get to know your HLS leaders and fellow members. Check out Feature Friday every week to learn about someone new! #MakingFridayFunAgain

    NIH halts $100 million moderate drinking study

    May 24, 2018 11:34 AM by billupsj

    The NIH halted a $100 million, 10-year study of moderate drinking largely funded in large part by the alcoholic-beverage industry. The decision to halt the study was made after news reports about the National Institute on Alcohol Abuse and Alcoholism’s involvement in soliciting the industry funding.  NIH Director Francis Collins has reportedly ordered two reviews of the study. The first will ‘determine if any process or conduct irregularities occurred with grants associated with the Moderate Alcohol and Cardiovascular Health (MACH) Trial,’ and the second will examine the scientific merit of the study.

    House To Consider 57 Opioid and Addiction Bills in June

    May 24, 2018 11:32 AM by billupsj

    The House Energy and Commerce committee is expected to bring 57 bills related to opioids and addiction to the House in June, where one week has been dedicated to deliberations on the proposals from the committee.  Among the bills is H.R. 5795, the Overdose Prevention and Patient Safety Act, that would change existing law to permit substance use disorder treatment records, currently governed under 42 CFR Part 2, to be shared in accordance with HIPAA for the specific purposes of treatment, payment and healthcare operations.

    Fentanyl and the Illegal Drug Market

    May 24, 2018 11:31 AM by billupsj

    Because fentanyl is an opioid analogue that can be created in a laboratory, unlike other illegal drugs that are plant-based, it has the potential to dramatically alter global drug policy.  While the impact of synthetic opioids has yet to be fully understood, it affects the basic nature of drug trafficking because it doesn’t require land to produce, agricultural workers to plant and harvest, or processing and transportation systems. “Producers can set up small labs within consuming countries and thus avoid the smuggling altogether,” along with advantages based on fentanyl’s potency.


    CMS Clarifies that "Gag Clauses" are Improper to Medicare Part D Plans

    May 24, 2018 11:26 AM by billupsj

    On May 17, 2018, CMS issued a memo to Medicare Part D sponsors indicating that “gag clauses” applicable to pharmacies are unacceptable. Some health plans and pharmacy benefit managers impose “gag clauses” on pharmacies, which prevent pharmacies from communicating to patients that prescription drugs may be less expensive if the patient pays for the drug out of pocket, rather than using insurance.  In these situations, the patient’s co-pay exceeds the amount the patient would pay if the patient paid cash for the drug. CMS’ memo stated that such “gag clauses” are unacceptable and contrary to CMS’ efforts to promote drug price transparency and lower drug prices.

    Link Found Between Military Trauma and Fibromyalgia

    May 24, 2018 11:24 AM by billupsj

    At the Annual Meeting of the American Psychiatric Association, a study was reported that suggests a link between military trauma and the risk of developing chronic pain. The American Psychiatric Association stated that service members who experience trauma, including sexual trauma, are at an increased risk of developing chronic medical conditions, including posttraumatic stress disorder (PTSD). 

    Five Clinical Lab Salesmen Sentenced For Bribing Physicians In $100 Million Scheme

    May 24, 2018 11:22 AM by billupsj

    Five former salepersons were sentenced for bribes paid to physicians for referrals to Biodiagnostic Laboratory Services LLC (BLS), of Parsippany, New Jersey.  The long running and elaborate scheme involved the salespersons, the BLS president and part owner, David Nicoll and his brother, Scott Nicoll, and physicians.  53 convictions, 38 against doctors, have resulted from the investigation in which doctors were bribed with cash to induce their referrals of blood specimens to BLS. The five salespersons admitted that sham consulting companies created and controlled by the salespersons were used to cover the fact that BLS was the true source of the bribes.

    Owner of Home Health Agency in Michigan Pleads Guilty for Role in Medicare Kickback Scheme

    May 24, 2018 11:21 AM by billupsj

    Atheir Amarrah, a resident of  West Bloomfield Michigan, and the owner of a Michigan home health agency, Prompt Care Home Health Services, Inc., pled guilty to charges against him due to his role in a Medicare fraud scheme.  Mr. Amarrah, 43, admitted to his role in paying and receiving kickbacks with sentencing is scheduled for Sept. 25.

    CMS Rejects Ohio's Waiver Request On Individual Mandate

    May 24, 2018 11:19 AM by billupsj

    On May 17,  CMS denied Ohio’s request for a State Innovation Waiver under section 1332 of the (ACA).  Previously, Ohio had submitted an application for the waiver of §5000A of the ACA, which requires applicable individuals to maintain minimum essential coverage or make a shared responsibility payment.  The Tax Cuts and Jobs Act changed the individual mandate penalty to $0, but it did not eliminate the requirement to maintain minimum essential coverage. CMS denied Ohio’s application because it was incomplete and failed to “include a description of any program implementing a waiver plan for providing coverage that meets section 1332 requirements.”  Section 1332 of the ACA permits the Secretaries of HHS and Treasury to approve a state’s waiver of certain requirements in the individual and small group insurance markets so long as it would: provide coverage as comprehensive and affordable as under the ACA; cover at least a comparable number of residents as under the ACA; and not increase the federal deficit.  CMS has approved 1332 waivers in Alaska, Oregon, Hawaii, and Minnesota. Wisconsin has submitted an application for a 1332 waiver and comments may be submitted to CMS through June 8, 2018.


    Feature Friday May 24, 2018

    May 24, 2018 11:14 AM by blakleyr

    Welcome to Feature Friday

    Happy Friday to all! As you know, #FeatureFriday is a way for the Health Law Section to Showcase some of our awesome Leaders and Members. We know that lawyers have busy and stressful jobs, so we wanted to inject a little fun into your work week!

    Today I am stoked to announce that royal wedding loving and Aunt Lydia hating, Denise E. Hanna is our Feature Friday.

    Denise E. Hanna, Co-Chair of Locke Lord LLP’s Health Care Practice Group and Managing Partner of the Firm’s Washington, D.C. office, concentrates her legal practice on representing health insurance companies, managed care organizations and their intermediaries on a range of regulatory and transactional matters. Denise’s legal experience includes lead roles in mergers and acquisitions for both strategic and financial buyers and sellers, joint ventures and other strategic transactions, internal restructures, change of control regulatory proceedings, managed care and provider contracting and commercial transactions.

    Among other honors, Denise has been named to The Best Lawyers in America for Health Care Law (2016-2017) and recognized by, Chambers USA for Health Care (2017-2018).

    Denise is a frequent speaker and writer on health reform and health law topics. Denise currently serves on the ABA Health Law Section’s Governing Council and Co-Chairs its Health Reform Task Force.

    Denise is a member of her Firm's Board of Directors and the former Chair of the Firm’s Diversity Committee.

    And now, Ladies and Gents, Denise E. Hanna...

    (Denise is pictured looking royal wedding ready! **Editor's Note- Try saying "royal wedding ready" fast 5 times)

    Q: What do you like most about being a lawyer?

    Denise: I enjoy that there continue to be knotty problems to solve, and novel deals to structure and document, for our health industry clients that continue to try to find better ways to deliver and pay for health care. I have the most fun when clients present new relationships that they’d like to form and I have to provide a legal structure to a mere set of ideas and aspirations and craft the documentation not from the latest form, but from my years of experience as a health care regulatory and deal lawyer.  It’s like building your dream house when you’re the architect, prime contractor and, then, the one who closes the sale.

    Q: Why health law?

    Denise: Dumb luck! Or, Providence!  Coming out of law school, my focus was on being a deal lawyer.  My second law firm just happened to be a health care boutique which needed another deal lawyer.  Although I naively resisted calling myself a health care lawyer for about 15 years, I really protested way too much. I so appreciate that my practice allows me to work with clients engaged in the most vital and personal decisions we, as individuals . . . as humans must face.  As their lawyer, I get to help clients develop better (i.e., more effective and efficient) ways to care for us when we’re sick and to keep us healthy.

    Q: What is one piece of advice that was given to you and has stuck with you?

    Denise: As a first-year lawyer, I recall asking a young partner, who already was a “star” in Los Angeles as a name partner in her own entertainment law firm: Just how does one get clients?  I had no idea what to do, and my family had no business connections.  The partner told me simply to just do good work for your clients.  Then, your reputation will spread and new clients will follow.  Well, for a long, long time I thought her advice was hooey.  However, once I was in the right law firm environment and, perhaps, the right frame of mind, the truth of those simple words – do a good job – have come true. 

    Q: How do you define success?

    Denise: What I realize now, at least for myself, is that success is elusive, whether it is achieving professional or personal goals.  Once you think you have it, it slips through your fingers as you recalibrate and refocus on new goals not yet achieved.  So, I try not to focus as much on goal fulfillment as happiness fulfillment.  Now, when I think about success, it’s just waking up happy and being excited about the day, and having the opportunity to engage with others and contribute to their personal well-being or professional endeavors in a positive way.  If we’re smiling or laughing and having a good time, I feel happy and successful – whether I’m at work or at play. 

    Q: Tell us three things that are on your bucket list.

    Denise: I’m not really a bucket list person.  Everyone is on my list.  That is, every good thing.  That is, as long as it doesn’t involve camping in the outdoors or encountering wild animals or bugs or any other primal sacrifice, like showers.

    Q: What fictional world or place would you like to visit?

    Denise: That’s a really hard one, since I’m so completely wrapped up into dystopian dramas, right now.  Well, I tell you that I probably shouldn’t venture to the Handmaid’s Tale dystopia because I’d make sure that Aunt Lydia knew that there is a special place in h*ll for women who torture other women. (Editor’s Note*** Denise would be a part of Mayday for sure! Under his eye…. ***eye roll***)

    Still, if it were only a visit, my friends would guess that I would want to drop in on the Walking Dead’s dystopia to hang out for a little while with all my friends in the “group” – that is, those who are still alive.  Who wouldn’t want to hang out with Rick and Daryl and Maggie and Carol. They are so, so Bad A$$.  Then, once I reminded myself that all the Four Seasons were dilapidated and there were no good restaurants left, I’d be out of there real quick. 

    Q: What is one thing people probably don’t know about you?

    Denise: Some people think I have tattoos . . . but alas, I don’t.

    Q: If you could uninvent one thing, considering the implications of uninventing it, what would it be and why?

    Denise: I would uninvent the “calorie” leaving me and everyone else free to eat their favorite foods without guilt or weight gain. Now, technically, I understand that if we had zero calories, we’d wither away to nothing, so I think I’d re-invent the ½ calorie to replace the full calorie.

    Q: What is one thing that people should know about the ABA Health Law section but they probably don’t?

    Denise: The HLS leadership is committed to serving the Section and in engaging in a thoughtful exchange of ideas about the complex and ever-evolving areas within health law.  HLS leadership appreciate how important these topics are to our society, both with respect to the businesses operated in the health industry and to consumers.  This is inspiring to me when many organizations seem to be more about self-promotion than the promotion of ideas.  Okay, granted, that may be more than one thing.  THE END.


    Long Live Denise!

    We would like to thank Denise for taking the time to participate in Feature Friday. The Health Law Section wants to thank all of our members for working hard to make our section awesome. Stay tuned for next week’s Feature Friday. Get to know your fellow HLS Leaders and Members. As Dani Borel said, we are #MakingFridayFunAgain. Have a great day!

    Seeking Program Proposals for Upcoming Conferences

    May 23, 2018 10:54 AM by blakleyr


    The ABA Health Law Section is seeking program proposals for the upcoming Washington Health Law Summit and Conference on Emerging Issues in Healthcare Law. As a benefit of your Health Law Section membership, you are being provided exclusive access to this request for proposals! Note that Section member proposals receive priority over other submissions.

    The deadline to complete the program proposal form is no later than Monday, June 18, 2018 to be considered. The Health Law Section continually strives to increase the participation of women, diverse ethnicities, disabled and LGBTQ speakers in Section activities, as well as to promote diversity in geographic location and practice settings. Please consider these criteria when proposing prospective speakers.

    Feel free to contact Danielle Daly (Danielle.Daly@americanbar.org) if you have any concerns.

    We value your participation, and look forward to your proposals!

    Feature Friday May 18, 2018

    May 18, 2018 9:34 AM by blakleyr

    Welcome to Feature Friday!

    Happy Friday to everyone! We would like to take a second and warmly welcome you to #FeatureFriday. Today we are happy to announce that our feature is none other than Vice Chair of the Distance Learning Committee and Young Lawyer Division Liason to Membership, Danielle L. Borel.

    Danielle is an associate at Breazeale, Sachse, & Wilson LLP in the Baton Rouge office, practicing in the areas of commercial litigation and healthcare litigation. Her principal areas of practice include litigation involving: healthcare provider licensing and payment disputes; trademark disputes; unfair trade practices and unfair competition; contract disputes; and general business and commercial issues. Ms. Borel litigates matters before the state and federal courts and before administrative courts. She has been involved in appeals before Louisiana administrative courts, Louisiana state courts, Louisiana federal courts, and the United States Court of Appeals for the Fifth Circuit. Ms. Borel has experience in representing pharmaceutical companies in opioid litigation brought by municipalities and counties.

    Ms. Borel received her Juris Doctor from Louisiana State University Paul M. Hebert Law Center, magna cum laude, in 2014 and was a member of The Order of Coif. She served as the Articles Editor for the Louisiana Law Review, and was a member of the Trial Advocacy and Moot Court boards. She received her Bachelor of Science from Louisiana State University, with honors, in 2011.

    (Dani is pictured looking pretty in pink!)

    Q: What do you like most about being a lawyer?

    Dani: I see the issues I deal with as logic problems, and I find them fun!

    Q: Why health law?

    Dani: Healthcare lawyers are masters of a very complicated, federally regulated area. Litigators are masters of persuasion, speaking, and handling adverse situations. I loved the idea of being a healthcare litigator because I saw it as the best of both worlds. I have the challenge of an intellectual subject matter and the fun of going to court. 

    Q: What is one piece of advice that was given to you and has stuck with you?

    Dani: Just keep swimming. When things seem overwhelming, the best way to conquer them is to take them one at a time.

    Q: What is one thing that people probably don’t know about you?   

    Dani: I make a mean blackberry pie.

    Q: How do you define success?

    Dani: I define success as being a well-rounded person. A successful person has a career they enjoy, is involved in their community, and has close friends and family. That is what I strive for.

    Q: What is one of the first things you bought with your own money?

    Dani: Own money? I was independent long before I was a working lawyer, but when I became a working lawyer, I purchased a very impractical car. It’s beautiful!

    Q: If you could uninvent one thing, considering the implications of uninventing it, what would it be and why?

    Dani: Electronic book readers. I like actual paper books and still buy at least one a month. Reading a book on an electronic reader diminishes the experience in my opinion.

    Q: Tell us three things that are on your bucket list.

    Dani: White water rafting, attending the D.C. Mardi Gras Ball, and attending the Kentucky Derby. 

    Q: What is your favorite thing to do in your free time?

    Dani: Be active. I’ve recently picked up golf, so most of my free time is spent on a golf course, riding bikes, or attending sporting events. 

    Q: What did you want to be when you were little?

    Dani: A “prostitute.” I meant prosecutor. Needless to say, I wasn’t allowed to watch Law & Order again after that class report.

    Q: What do you like about the ABA Health Law Section and what is one thing you wish people knew about it?        

    Dani: I like how welcoming the Health Law Section is and how friendly the members are.  I wish people knew that there are multiple ways to be involved.


    Huge thanks to Dani for taking the time to participate in Feature Friday this week. THANKS, Dani! Get to know your ABA Health Law Section Leaders and fellow members. Keep your eyes open for next week's Feature Friday!

    Co-Defendant’s "Indispensable Status" Keeps Baltimore's Opioid Lawsuit Out of Federal Court

    May 17, 2018 3:15 PM by billupsj

    Defendants in the City of Baltimore’s lawsuit alleging conspiracy to overprescribe opioids failed in their attempt to remove the state court action to federal court.  One local healthcare provider foiled complete diversity and could not be severed from the case, as the court deemed them an indispensable party.  

    OIG Congressional Testimony on the 340B Drug Pricing Program

    May 17, 2018 3:05 PM by billupsj

    On May 15, 2018, Ann Maxwell, the OIG’s Assistant Inspector General for Evaluation and Inspections, testified before the Senate Committee on Health, Education, Labor, and Pensions, discussing ways to protect the integrity of the 340B Drug Pricing Program.  Ms. Maxwell noted that there are two vulnerabilities with the 340B Program that impede its effective operation and oversight: “(1) a lack of transparency that prevents ensuring that 340B providers are not overpaying pharmaceutical manufacturers and that State Medicaid programs are not overpaying 340B providers; and (2) a lack of clarity regarding program rules that creates uncertainty, resulting in inconsistent program implementation and limited accountability.”  In order to address these vulnerabilities, Ms. Maxwell testified that the OIG recommends increasing transparency to support payment accuracy (HRSA should share ceiling prices with 340B providers and State Medicaid agencies through CMS, and require State Medicaid agencies to use claim-level methods to identify 340B claims), and clarifying rules to ensure that the 340B Program operates as intended (clarify the definition of an eligible patient and whether 340B providers must offer discounted 340B prices to uninsured patients).  Ms. Maxwell testified that since both HRSA and CMS have stated that they do not have sufficient authority to carry out these recommendations, the OIG encourages Congress to act. 

    Hospital Operator Agrees to Pay $14.25 Million to Settle FCA Allegations

    May 17, 2018 3:02 PM by billupsj

    Mercy Health of Cincinnati Ohio, has agreed to pay $14.25 million to settle allegations of improper relationships with referring physicians in violation of the FCA.  Mercy Health is a nonprofit organization that operates healthcare facilities in Ohio and Kentucky.  Mercy Health self-reported certain arrangements with six employed physicians that exceeded the fair market value of their services.

    South Texas Doctor Charged in $240 Million Health Care Fraud and Money Laundering Scheme

    May 17, 2018 3:00 PM by billupsj

    A McAllen, Texas, physician was charged in an indictment in connection with a $240 million health care fraud and international money laundering scheme.  The indictment alleges that beginning in 2000, Dr. Jose Zamora-Quezada and his co-conspirators engaged in numerous improper activities, including falsely diagnosing patients, with various degenerative diseases, including rheumatoid arthritis, administering or prescribing unnecessary medications, and conducting fraudulent, repetitive, and excessive medical procedures to increase revenue and fund his lavish and opulent lifestyle.  

    UC Davis Health and Adventist Health Lodi Memorial Partner on Pediatric Care

    May 17, 2018 2:59 PM by billupsj

    UC Davis Health and Adventist Health Lodi Memorial (Lodi) have entered into a professional services agreement to expand pediatric neonatal care services at Lodi.  UC Davis physicians and nurses will provide care through a Level II Neonatal Intensive Care Unit as well offer expanded inpatient and outpatient pediatric services at Lodi.

    Emory Partners with Australian Hospital for Unique teleICU Arrangements

    May 17, 2018 2:54 PM by billupsj

    Emory has also agreed to partner with Royal Perth Hospital in Australia and Philips, a health technology company, for intensive care coverage.  Because of the 12-hour time difference, Emory practitioners will be able to work at Royal Perth Hospital during daytime hours while will providing remote teleICU coverage for the night shifts at Emory.  The Emory providers will utilize remote Phillip’s electronic intensive care unit technology to provide backup support to the care teams on-site in the Atlanta locations.  

    Emory Healthcare Closer to Completing Partnership with DeKalb Medical

    May 17, 2018 2:52 PM by billupsj

    The FTC approved a proposed partnership between Emory Healthcare and DeKalb Medical, and the proposed transaction will now proceed to be reviewed by the Georgia Attorney General.  If approved, the transaction is anticipated to close within 100 days with DeKalb joining the Emory Healthcare System. DeKalb consists of 3 hospitals and 50 physician group offices with a medical staff of over 800+ doctors.

    Feature Friday May 11, 2018

    May 11, 2018 2:18 PM by carsons

    Welcome to Feature Friday

    Happy Friday to all! Today we have a special treat for Feature Friday. Our ABA Health Law Section Council Chair, Hilary Young has been roped into our super fun Friday feature.

    And now, ladies and gentlemen, Hilary Young!

    Hilary Young is a partner with Joy & Young LLP. Her practice focuses on Texas and federal regulatory, licensing, certification, and operations matters. Ms. Young is the current Chair of the ABA Health Law Section. In addition, she served on the State Bar of Texas Health Law Council and the Texas Board of Legal Specialization Examination Committee. Ms. Young is board certified in Health Law by the Texas Board of Legal Specialization. She earned her J.D. from the University of Texas School of Law, an M.A. in Latin from the University of Oklahoma, and an A.B. in Latin and History, Cum Laude, from Duke University.  Before entering private practice, Ms. Young served as a law clerk for the late Jerre S. Williams, Senior Judge for the United States Court of Appeals for the Fifth Circuit.

    (Crikey! Now, that's a croc! Check out our fearless Section Chair conquering her pathological childhood fear of death by alligator by posing with a friend during a swamp tour in New Orleans at EMI in 2017.)

    Q: What do you like most about being a lawyer?  

    Hilary: I like having and using the perspective and analytical skills that I acquired in law school and through practice.  And I like working with my clients and colleagues to solve problems, comply with rules, and resolve disputes.


    Q: Why health law?  

    Hilary: Health law is a great fit for me substantively and procedurally.  First, I grew up interested in medicine.  My father was a doctor whose internal medicine and hematology training took him into oncology before it was a widely recognized specialty.  I loved discussing his work with him.  I worked in his office and later in the emergency department of a community hospital during high school.  But my preference for Latin, history, and theatre studies over chemistry led me to teaching rather than medical school.  After working for ten years I went to law school.  The skills I enjoy include a combination of research, writing, teaching, counseling, collaborating with others, problem-solving, and seeking win-win solutions.  A litigation practice was not for me, and health law was.  There are many different ways to practice health law.  For me, the fun is in advising health care providers, typically those working in hospitals, on how to operate in compliance with the rules and on how to demonstrate compliance to regulators.  We often work with the same client contacts and the same regulators, and it is gratifying to have positive working relationships with both groups.


    Q: What is one piece of advice that was given to you and has stuck with you?  

    Hilary: Answer the client’s question—and don’t just analyze the law and tell a client “no” if there is a way the client can legally achieve their goals.


    Q: If you could uninvent one thing, considering the implications of uninventing it, what would it be? 

    Hilary: Today it would be the atomic bomb.  While the bomb arguably brought WW2 to an abrupt close, and nuclear energy offers some environmental upside in generating power, this technology poses an unacceptable threat to the world if it is under the control of unstable and mercurial leaders.


    Q: How do you define success? 

    Hilary: Doing satisfying work, having a wonderful group of friends and family, being able to contribute and help others, having enough resources to not worry about how to cover my bills and have some extra to put out into the world, and laughing every day.


    Q: If you were stuck on a desert island and could have 3 things with you, what would those 3 things be?

     Hilary: A knife, a magnifying glass, and a blanket.


    Q: Tell us three things that are on your bucket list.  

    Hilary: Go to Hawaii, go to Australia and New Zealand, and spend an extended period of time in Paris.


    Q: Who is one person, dead or alive, that you would like to have dinner with? Why?  

    Hilary: Amal Clooney.  I would love to hear her story, what drew her to her practice and her commitment to human rights, and how she forged that path.


    Q: Why are ABA Health Law Section important to you?  

    Hilary: The professional community.  I love the Section and being involved with it.  Initially, the Section provided me with helpful information and tools to support my practice.  But then I attended my first Emerging Issues Conference in 2002, and over the next few years the Section became an important community for me.  I now have significant mentors, close friends, and wonderful colleagues around the country.  If I have a thorny issue, all I have to do is “phone a friend” from the Section to get guidance and support.  I have been able to get involved through various leadership positions.  And I love going to our in-person meetings and conferences and seeing everyone.


    Q: What have you liked most about being the Section Chair? 

    Hilary: There are several things that come to mind.  I love working closely with Simeon Carson, the Section Director, and also with the staff and officers to deal with issues and keep the Section humming along.  I love the in-person Council meetings, where magic can happen—people come up with ideas that spark more ideas from others, and a new pathway suddenly opens up.  And I love being a part of the SOC Executive Committee and OneABA Working Group, giving the Section a voice in the bigger organization, and I hope communicating the Section’s long-standing commitment to being innovative and inclusive in serving our members and supporting the goals of the ABA.


    I think we can all agree that Hilary is a rock star. The Health Law Section would like to thank Hilary for participating in Feature Friday and for her continued service to the ABA and the law profession.


    CMS Issues Update on Medicare "Low Volume" Payments to Qualifying Hospitals

    May 10, 2018 11:56 AM by billupsj

    On April 24, 20918, CMS announced an update on the implementation of section 50204 of the Bipartisan Budget Act of 2018, which extends temporary changes to the Medicare low-volume payment adjustment through federal fiscal year (FY) 2018 for qualifying hospitals.  For FY 2018, low-volume hospitals will continue to be defined as those that are more than 15 road miles from another comparable hospital and that have up to 1,600 Medicare discharges. For fiscal years 2019 through 2022, the add-on payment will be calculated using a continuous linear sliding scale ranging from 500 total discharges to 3,800 total discharges. The update serves to provide some assurance to small rural hospitals across the nation that benefit from the payment that must be renewed regularly by Congress.

    Opioid Abuse Leads to Patient Endangerment

    May 10, 2018 11:54 AM by billupsj

    A nurse at a hospital in Washington state was arrested for infecting patients with hepatitis C while diverting pain medications from IV preparations. Cora Weberg, 31, is facing second-degree assault charges involving the intentional infection of two patients with the disease as well as the misappropriation of drugs from the Puyallup Good Samaritan Hospital.  The nurse discovered she was infected with Hepatitis C in March 2018.

    CMS Provides Clarity on Supplemental Benefits and Uniformity Requirements

    May 10, 2018 11:36 AM by billupsj

    On April 27, CMS released additional guidance on Medicare Advantage policy changes for the 2019 plan year.  The guidance addresses the expansion of supplemental benefits and the reinterpretation of the uniformity requirement.  The agency will not permit plans to be structured in a discriminatory manner but will permit plans to condition cost-sharing reductions or provide access to targeted supplemental benefits based on certain requirements.  CMS stated their expectation that the expanded definition of supplemental benefits will be used by plans to “make adjustments to their annual supplemental benefit offerings based on the expected needs of their plan population.”  These policy changes will provide plans with increased flexibility to design plans in innovative ways. 

    Five Physicians from Drug Addiction Treatment Practice Charged with Unlawful Distribution and Health Care Fraud

    May 10, 2018 11:34 AM by billupsj

    Five physicians engaged as contractors by Redirections Treatment Advocates, LLC, an opioid addiction treatment practice in Pennsylvania and West Virginia, have been indicted on charges of illegally dispensing controlled substances and Medicare and Medicaid fraud.   According to the indictment, the defendants created and distributed unlawful prescriptions for Subutux and Suboxone, forms of buprenorphine, a drug used to treat individuals with addiction.  The defendants were charged with health care fraud for allegedly causing fraudulent claims to be submitted to the federal health benefits programs for payments to cover the costs of the unlawfully prescribed buprenorphine.  The investigation was part of an effort by the Department of Justice to use data to target and prosecute individuals who commit opioid-related health care fraud including physicians who "ignore their oath to do no harm."


    Physicians To Pay $700,000 to Settle FCA Allegations Regarding Improper Relationship with Drug Testing Laboratory

    May 10, 2018 11:33 AM by billupsj

    On Monday, May 7, Robert Fetchero, D.O., of Jeannette, Pennsylvania, Sridhar Pinnamaneni, M.D., of Windermere, Florida, and Thelma Green-Mack, M.D., of Zionsville, Indiana, separately agreed to settle allegations that they each received improper payments for referrals from Universal Oral Fluid Laboratories, a Greensburg, Pennsylvania, drug testing lab.  By agreeing to accept these payments, the three physicians caused false claims to be submitted to Medicare for drug testing services. According to the DOJ, the physicians referred Medicare patients to the laboratory for drug testing services while engaged in a financial relationship with the lab. 

    CMS Approves New Hampshire Section 1115 Demonstration; Rejects Lifetime Limits in Kansas

    May 10, 2018 11:31 AM by billupsj

    On May 7, CMS approved New Hampshire’s section 1115 demonstration project requiring work or community engagement as an eligibility requirement.  On the same day, the agency partially denied a waiver request from Kansas by rejecting its request  to impose lifetime limits on Medicaid benefits. CMS believes the New Hampshire waiver will “promote health and wellness through increased upward mobility.”  New Hampshire’s demonstration project will eliminate retroactive coverage and require beneficiaries who gained coverage under Medicaid expansion to participate in 100 hours per month of work or community engagement activities.   The agency previously approved similar waivers for Kentucky, Arkansas, and Indiana, and CMS issued a State Medicaid Director letter on January 11, 2018, that encourages states to submit demonstrations that test work and community engagement requirements.  In rejecting the portion of the Kansas section 1115 waiver that would have imposed a lifetime limit, Administrator Verma stated that “community engagement programs should be designed to support a pathway out of poverty for individuals and promote overall health and well-being.”  The decision to reject a lifetime limit provides the Trump administration’s first views on the limits of section 1115 demonstration authority.   


    Elliott Management Offers to Acquire athenahealth

    May 10, 2018 11:29 AM by billupsj

    Elliott Management Corporation (Elliott), a private investment firm and presently the owner of 9% of the outstanding common stock of athenahealth, Inc., released a letter detailing its unsolicited offer to acquire all of athenahealth.  Elliott asserted that athenahealth, as a public company, is “not working” and citing the company’s great potential, proposed to acquire the company for $160 per share in cash.  The offer provides athenahealth a total market value of approximately $6.9 billion and represents a 27% premium to the stock price. The Board of athenahealth responded with an announcement that it will review the offer from Elliott. 

    Baptist Health to Purchase Hardin Memorial Hospital

    May 10, 2018 11:27 AM by billupsj

    Baptist Health, the largest not-for-profit health system in Kentucky, and Hardin Memorial Hospital (HMH) have agreed to a $361 million asset purchase agreement, subject to approval by HMH’s board.   HMH, a 300-bed facility currently owned by Hardin County, Kentucky and managed by Baptist Health for the past 20 years, will be renamed Baptist Health Hardin.  Pending regulatory approval, the sale is expected to finalize in December of this year.

    May 10th HIPAA Tweet Chat Questions

    May 9, 2018 11:43 AM by carsons

    Join Us for our #HLSChat on May 10th at 12:00PM EST


    Below you will find a list of questions to be covered during our #HLSChat.

    How does HIPAA align with and support digital health solutions? 

    How does information blocking manifest and what can be done to stop it? 

    How can HIPAA enhance and promote use of digital communication tools?

    What surprising activity for use/disclosure of health information is permitted? 

    What can be done to prepare for effective communication during emergencies?

    Bonus: What law or regulation would you like to see enacted or removed to help digital health? 


    Don't forget to join us at 12:00pm EST. Happy tweeting! 

    Feature Friday May 4, 2018

    May 3, 2018 5:02 PM by clarkp

    Welcome to Feature Friday

    The ABA Health Law Section would like to take this time to introduce you to another one of our awesome members. This week we would like you to meet the Co-Chair of the Distance Learning Committee and the Vice-Chair of both the EMI Planning Committee and the Marketing Committee, Matt Fisher.

    Matt is a Partner and Chair of the Health Law Group at Mirick O’Connell and he attended Suffolk University Law School. 

    And now for the Feature Friday questions!

    (Matt is pictured on the left, not to be confused with the gentleman on the right.)

    Q: What do you like most about being a lawyer?  

    Matt: I like constantly learning about new business ideas and developments from working with clients. There is no stop to the learning opportunities, including in areas that I would not necessarily have found for myself.

    Q: Why health law?

    Matt: I like health law because it is an essential part of society and has the opportunity to help many people. If I can make a project or idea come to fruition for a provider or someone helping the industry, then there can be a much larger and widespread impact than in many other areas. As with the general idea of learning, I also get to see many innovative concepts and help to find a place for them within the regulatory environment.

    Q: What is one piece of advice that was given to you and has stuck with you?

    Matt: If you do not enjoy what you are doing, then try something else. This was a lesson my parents taught and encouraged and one that I have followed. When you find something that you enjoy and are passionate about, then it becomes a lot easier.

    Q: How do you define success?

    Matt: I define success as being happy and content with what you are doing. That does not mean being content to stay still, but having goals in mind and working toward them. There is never a destination so much as an ongoing journey.

    Q: If you were stuck on a desert island and could have 3 things with you, what would those 3 things be?

    Matt: If I were stuck on a desert island I would want an e-reader with unlimited books and unlimited battery power, an unending supply of New England IPAs (preferably from Tree House), and my wife.

    Q: Tell us three things that are on your bucket list.

    Matt: People know some of these, but 3 things would be to visit Australia, to visit a brewery in every US state, and to see my kids have happy lives.

    Q: What fictional world or place would you like to visit?

    Matt: I want to visit the Cosmere and preferably as someone like Hoid. (**Editor’s Note- for those of you who are not familiar with Cosmere, google it. I did and now I wouldn’t mind going there either.)

    Q: What is your favorite part about PLI?

    Matt: This will be my first time attending PLI. Like all Health Law Section events though, I am looking forward to connecting with old friends and making new ones.


    Big shoutout to Matt for being super awesome and participating in our second Feature Friday.

    Join us for the Physicians Legal Issues Conference (PLI) on June 7-9 in Chicago. To find out more information, please visit: http://ow.ly/QOV530jcHcb

    Get to know your ABA HLS Leaders. Look out for next week's #FeatureFriday and see who we will feature next!

    More States Considering Medical Marijuana As An Opioid Alternative

    May 3, 2018 12:24 PM by billupsj

    The Illinois Senate voted on April 26 to allow doctors to prescribe medical marijuana as an alternative to opioids and those suffering from opioid addiction would be eligible to apply for a medical marijuana program card. Colorado has proposed a new bill that would allow doctors to write a medical-marijuana recommendation for any condition, for which a physician could prescribe an opiate for pain. The Colorado bill is currently pending in the state Senate.

    U.S. House Energy and Commerce Health Subcommittee Hearing May 8

    May 3, 2018 12:22 PM by billupsj

    On May 8, the House Energy and Commerce Subcommittee on Health will hold a hearing to discuss the Overdose Prevention and Patient Safety Act, which proposes to amend 42 CFR Part 2 that governs confidentiality of substance use records. This Act is intended to align 42 CFR Part 2 with HIPAA.  A number of healthcare organizations, including the AHA, have formed a coalition and have advocated for alignment to ensure that providers have access to their patient's entire medical history. The Substance Abuse and Mental Health Services Administration recently released a final rule which takes some steps to modernize Part 2, but, according to the AHA, it does not go far enough.  The Act includes changes clarifying definitions for "treatment," "payment," "healthcare operations," and "protected health information" and also strengthens the protection of patient confidentiality in criminal proceedings.

    CMS Announces Expanded Access to Medicare Advantage Data

    May 3, 2018 12:19 PM by billupsj

    CMS will make Medicare Advantage encounter data available to researchers for the first time, beginning with the 2015 benefit year.  This data has become increasingly important as more than one-third of beneficiaries are now enrolled in Medicare Advantage plans.  CMS will provide annual updates and intends to also release data from Medicaid and the Children’s Health Insurance Program in the future.  CMS Administrator Verma stated that “[d]ata has the potential to help produce better, more targeted treatments for patients, improving their quality of life while at the same time reducing costs.”

    Nevada Physicians Agree To Pay $1.5 Million To Settle FCA Allegations

    May 3, 2018 12:05 PM by billupsj

    Cardiovascular and Thoracic Surgeons of Nevada, Inc. (CTS) and its principal physician, Dr. Bashir Chowdhry, have reached a settlement with the US to resolve False Claim Allegations.  CTS will pay $1.5 million to resolve allegations that CTS improperly billed federal healthcare programs for surgical services not actually provided, and for higher cost services than those actually provided to its patients.

    CMS Focuses on Patient-Centered Care and Reducing Paperwork Burden in Proposed Payment Rules

    May 3, 2018 12:03 PM by billupsj

    CMS has proposed payment system changes that enhance patient-centered care while reducing the administrative burden on providers. In particular, CMS is proposing a modernized system for SNF payment that aims to incentivize providers to treat the needs of the whole patient by tying payment to patients’ needs rather than to the volume of services provided. CMS also proposed a new payment system rule for IRFs that recognizes telecommunications advances by permitting rehabilitation physicians to perform certain meetings without being physically present. CMS proposed updates to the Hospice Wage Index and Payment Rate Update and the IPF Prospective Payment System, as well.

    Maine Sued for Failure to Expand Medicaid

    May 3, 2018 12:00 PM by billupsj

    Advocacy groups and residents of Maine have filed a lawsuit against Maine’s Department of Health and Human Services (DHHS) for failing to expand Medicaid.  Under the terms of the Medicaid Expansion Act, passed by Maine voters in November, 2017, the state was required to submit a state plan amendment to CMS by April 3, 2018.  Governor LePage has said he will not expand Medicaid unless the legislature provides adequate funding. Despite the Governor’s earlier vetoes of Medicaid expansion legislation, Maine law does not permit a Governor to veto a law passed by citizens’ initiative.  The lawsuit asks the Court to require DHHS to submit the state plan amendment within three days and implement Medicaid expansion by July 2, 2018.

    Ohio submits 1115 Demonstration Proposal

    May 3, 2018 11:59 AM by billupsj

    On April 30, Ohio submitted a Section 1115 demonstration proposal to CMS that would require adults in the Medicaid expansion population to work at least 20 hours a week or be engaged in other community engagement activities.  New enrollees would need to meet the work requirement and current enrollees would need to meet the requirement during their annual eligibility renewal. Ohio estimates that 95% of current enrollees will be exempt or meet the requirements, if approved.  Approximately 36,000 enrollees may need to find work or community engagement activities to remain enrolled in Medicaid coverage. Ohio anticipates that 18,000 enrollees will lose coverage. CMS has previously approved Section 1115 waivers containing work requirements from Kentucky, Indiana, and Arkansas.  The Kentucky waiver is being challenged in the U.S. District Court for the District of Columbia.  Oral arguments have been set for June 13, 2018.

    Can Republican-Lead States Succeed In Enjoining The Affordable Care Act?

    May 3, 2018 11:47 AM by billupsj

    Beginning January 1, 2019, the Tax Cuts and Jobs Act of 2017 reduces to zero dollars the tax penalty imposed by ACA on many individuals who fail to maintain minimum essential coverage (i.e., the individual mandate), thus gutting a critical pillar of ACA and potentially creating a new path to invalidate all of ACA’s health insurance market reforms and Medicaid expansion.  As a result of the new law, multiple state attorneys general joined in filing a federal lawsuit to invalidate the ACA, contending that the individual mandate should fail on constitutional grounds because it will no longer serve as a mechanism to raise tax revenues. On April 26, these same attorneys general filed a motion seeking to preliminarily enjoin HHS and IRS from enforcing ACA’s health insurance market reforms (e.g., guaranteed issue coverage and community-rating) that are inextricably bound to the individual mandate in advance of the sunset of the mandate’s tax penalty.

    Interestingly, plaintiffs rely on the U.S. Supreme Court’s decision in National Federation of Independent Business v. Sebelius as providing the grounds for now rendering the mandate unconstitutional. Plaintiffs contend that compelling individuals to purchase health insurance, without the benefit of tax revenues, exceeds Congressional power under the Commerce Clause – a conclusion reached in a dissenting opinion signed on by five Justices.  Thus, the United States should not continue to enforce the individual mandate and, by implication, the remainder of ACA, because Congress, in its legislative findings and as codified in the ACA, determined the mandate to be essential to, and intertwined with, ACA’s health insurance reforms.

    The plaintiffs intimate that states can better design and regulate their unique health insurance markets and that widespread and immediate relief (e.g., alleviate consumer spending on high-cost ACA coverage, save States the expense of propping up failing ACA coverage and eliminate increased federal spending on premium subsidies) would follow a preliminary injunction of ACA.   It is difficult to speculate on how the court will respond to plaintiffs’ claims that immediate relief is warranted when the individual mandate tax penalty is not repealed until year-end. Additionally, plaintiffs have failed to address what will happen to Americans covered by ACA exchange plans, who actually want or need to maintain coverage, if the federal government is compelled to immediately stop subsidizing such coverage.

    Federal Agencies Issue Clarification on GOT Rules

    May 3, 2018 11:45 AM by billupsj

    In 2010, an interim final rule was issued implementing the ACA’s patient protection provisions that are applicable to non-grandfathered group and individual plans. One of the protections included in the law requires affected health plans to cover out-of-network charges without prior authorization and at in-network cost sharing.  Further, benefits must be based on the greater of (1) the payment negotiated with in-network providers, (2) the payment made to out-of-network providers, or (3) the Medicare payment rate. This approach is colloquially known as the “Greater of Three” or GOT.

    In May 2016, the American College of Emergency Physicians (“ACEP”) filed a lawsuit asserting that the GOT final rule should be invalidated under the Administrative Procedure Act.  ACEP alleged that the GOT rule (1) did not ensure a reasonable payment, (2) concerns relating to the purported deficiencies in the second prong of the GOT e.g. lack of transparency and manipulation, were not addressed, and (3) the request for the creation or designation of an out-of-network claims pricing database for use when calculating the second GOT prong was ignored.  On April 30, 2018, in response to the court’s requirement that they respond to ACEP allegations, the Departments of Treasury and Labor, as well as HHS, issued a clarification of the final GOT regulations.  The agencies noted that (1) patients have a right under the ACA and ERISA to obtain transparent information supporting the calculation of their benefits, (2) explained that the proposed database would be problematic, and (3) pointed out that it is a greater of the three prong results. “Thus, [the agencies] * * * maintain that the existing GOT regulation provides a statutorily supportable, and also a more practical, and cost-effective approach for group health plans and health insurance issuers to determine the required minimum payment amounts.” Consequently, no change was made to the GOT rule. The case now returns to federal court for its evaluation of this decision.

    IRS Reverses Change to Limit on Contributions to HSA

    May 3, 2018 11:42 AM by billupsj

    Earlier this year, the IRS reduced the 2018 maximum amount that an individual with family coverage was permitted to contribute to a health savings account HSA from $6,900 to $6,850.  The change was a result of the Tax Cuts and Jobs Act enacted late last year, which required the IRS to recalculate certain provisions that are adjusted for inflation.   

    Last week, the IRS issued Rev. Proc. 2018-27, reversing the reduction and reinstating the original limit of $6,900 for those with family coverage.


    University of Kansas Health System and Great Bend Regional Hospital Signed Letter of Intent

    May 3, 2018 11:37 AM by billupsj

    The University of Kansas Health System and Great Bend Regional Hospital signed a letter of intent for the University of Kansas Health System to acquire Great Bend Regional Hospital and its affiliated clinics.  The transaction is expected to close summer of 2018. The University of Kansas Health System currently includes the University of Kansas Hospital, HaysMed, Pawnee Valley, and the University of Kansas Health System St. Francis Campus.


    Humana Launches Hospital Incentive Program

    May 3, 2018 11:36 AM by billupsj

    Humana announced the launch of a national, value-based care Hospital Incentive Program (HIP) to be offered to general acute hospitals.  The HIP’s objectives are to deliver more integrated care and reduce duplicative services, readmissions, and complication rates, and the HIP will offer compensation based on improvement/performance in three areas: patient experience; patient safety; and patient outcomes.  Quality improvement and performance will be tracked by measures including infection rates, care coordination, and palliative care and will incorporate programs developed by the Joint Commission.

    The Final 60-Day Overpayment Rule: Overview, Recent Developments, and What It Means for You and Your Clients

    April 27, 2018 11:14 AM by billupsj

    Tues April, 17, 2018

    To view slides, click here
    To view recording, click here

    In this webinar, Hillary provided a brief overview of the 60-day Overpayment Rule and its intersection with the False Claims Act, followed by an in-depth discussion of recent updates and relevant cases and settlements in order to address those questions with which practitioners may still struggle

    Calvin Marshall, Chambliss, Bahner & Stophel PC, Chattanooga, TN 

    Hillary Stemple, Arent Fox, Washington, DC

    Feature Friday April 27, 2018

    April 27, 2018 10:36 AM by carsons


    Welcome to Feature Friday!

    The ABA Health Law Section would like for everyone to get to know their leaders a little better. So, we will be highlighting our leaders through Feature Friday (#FeatureFriday).

    For our first ever Feature Friday, we would like to introduce you to Council Vice-Chair candidate for FY 2019, Hal Katz. Of course, many of you already know him, but Hal was gracious enough to answer our Feature Friday questions. 

    But first, let’s get the formalities out of the way. Hal is a Partner at Husch Blackwell LLC in Austin, Texas and is a member of the firm’s Healthcare, Life Sciences and Pharmaceuticals Strategic Business Unit.  He is Board Certified in Health Care Law by the Texas Board of Legal Specialization, and focuses on corporate, transactional and regulatory matters for traditional providers and innovative businesses in the healthcare space.  Hal received his Doctor of Jurisprudence from the University of Houston Law Center and his Bachelor of Arts from the University of Texas in Austin. 

    Now, on to our Feature Friday questions!

    Q: What do you like most about being a lawyer?

    Hal: Having the ability to use the law to help people.

    Q: Why health law?

    Hal: Truth: I stumbled into it.  I was clerking in the litigation section, but the firm only had a health law position open.  In spite of being at a law school that had one of the best health law programs in the country, health law was completely unknown to me.

    Q: What is one thing that people probably don’t know about you?

    Hal: I’m an introvert at heart!

    Q: What is one piece of advice that was given to you and has stuck with you?

    Hal: Success is 85% attitude, 15% aptitude.

    Q: How do you define success?  

    Hal: Leaving the world a better place than how I found it.

    Q: If you weren’t a lawyer, what would you be?

    Hal: A therapist.

    Q: Tell us three things that are on your bucket list.

    Hal: Fly fishing in Alaska, African Safari, and Traveling Asia (Thailand, India and Vietnam).


    Big thanks to Hal for agreeing to be our first feature.
    Get to know your ABA HLS Leaders. Look out for next week's #FeatureFriday and see who we will feature next!

    LabCorp and Mount Sinai Enter Agreement to Enhance Laboratory Operations

    April 26, 2018 2:40 PM by billupsj

    LabCorp, a global life sciences company, and Mount Sinai Health announced a contract to enhance laboratory operations at Mount Sinai’s seven acute care hospitals.  LabCorp is now the primary reference laboratory for Mount Sinai and will help improve the quality of laboratory services through standardization and greater efficiency.  This agreement is in addition to several previous arrangements between LabCorp and Mount Sinai, including LabCorp’s acquisition of Mount Sinai’s clinical outreach laboratories in 2017. 

    HHS Releases Mental Health and Substance Use Disorder Parity Action Plan

    April 26, 2018 12:15 PM by billupsj

    The 21st Century Cures Act directed HHS to develop an Action Plan related to the ongoing implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). The Action Plan provides a brief background on parity; description of the public stakeholder listening session that was held on July 27, 2017; and outlines recent and planned actions to continue parity enforcement.

    Recent and planned actions of the Plan are organized into five categories: reporting and enforcement; disclosure requirements and increased transparency; consumer and compliance tools; state technical assistance, and research. Some highlights of planned actions include:

    • the Substance Abuse and Mental Health Services Administration is in the process of developing a toolkit targeted at state insurance regulators and behavioral health authority staff, human resources professionals and insurance executives to educate these groups on what parity is and how to comply with federal parity laws and regulations;

    • HHS plans to continue to update the Parity Portal for consumer in evaluating whether they have experience a parity violation;

    • Department of Labor will continue to release data and summaries of parity enforcement activities.


    HHS Takes New Steps to Implement Value-Based Agenda

    April 26, 2018 12:12 PM by billupsj

    On April 24, HHS announced new steps in implementing HHS Secretary Alex Azar's value driven healthcare agenda as part of the CMS Fiscal Year 2019 Inpatient Prospective Payment System (IPPS) proposed rule released on the same date.

    On April 23, CMS disclosed public suggestions to reshape the CMS Medicare Innovation Center, which the Affordable Care Act funded with $10 billion.  “The [public] responses focused on a number of areas that are critical to enhancing quality of care for beneficiaries and decreasing unnecessary cost, such as increased physician accountability for patient outcomes, improved patient choice and transparency, realigned incentives for the benefit of the patient, and a focus on chronically ill patients. In addition to the themes that emerged around the [Request for Information] RFI’s guiding principles and eight model focus areas, the comments received in response to the RFI also reflected broad support for reducing burdensome requirements and unnecessary regulations.”

    Additionally, CMS addressed the proposed policy changes in a fact sheet and the fiscal impact is addressed as follows:

    The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users is approximately 1.75 percent. This reflects the projected hospital market basket update of 2.8 percent reduced by a 0.8 percentage point productivity adjustment. This also reflects a proposed +0.5 percentage point adjustment required by legislation, and the -0.75 percentage point adjustment to the update required by the Affordable Care Act.

    CMS projects that the rate increase, together with other proposed changes to IPPS payment policies, will increase IPPS operating payments by approximately 2.1 percent, and that proposed changes in uncompensated care payments, capital payments, and the changes to the low-volume hospital payments will increase IPPS payments by an additional 1.3 percent for a total increase in IPPS payments of 3.4 percent.


    CMS Requests Comments for Proposed Rule Changes to IPPS and LTCH PPS

    April 26, 2018 12:10 PM by billupsj

    CMS has proposed changes to its Medicare Inpatient Prospective Payment and Long-Term Acute Care Hospital Prospective Payment Systems.  These proposed changes seek to advance its priority to reduce the administrative burden on hospitals while increasing price transparency and interoperability.  According to CMS, the proposed rule eliminates 25 total measurements across 5 quality-reporting and pay-for-performance programs, reducing more than 2 million burden hours, and resulting in cost saving of approximately $75 million.

    Under the rule, CMS will require hospitals to post a list of their standard charges online, and it renames the “Meaningful Use” program to “Promoting Interoperability.” It will also update the LTCH PPS standard Federal payment rate by 1.15 percent and eliminate the 25-percent threshold policy.  The proposed changes further include a 1.75 percent increase in operating payment rates under the IPPS for general acute care hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users.

    Finally, the rule changes seek to ease documentation requirements for payment under Medicare Part A by no longer requiring certification statements detailing “where” in the medical record the required information can be found, removing the requirement for a written inpatient admission order to be present in the medical record and other actions.

    Deadline to submit comments on the proposed rule is June 25, 2018.


    AHRQ National Guideline Clearinghouse Will Lose Funding after July 16th

    April 26, 2018 12:02 PM by billupsj

    AHRQ National Guideline Clearinghouse (NGC) will no longer have funding after July 16th. and as a result, its website will no longer be available.  The NGC is a publicly available database of evidence-based clinical practice guidelines and related documents. It provides internet users with free online access to updated and new guidelines. NGC was originally created by AHRQ in partnership with the American Medical Association (AMA) and the American Association of Health Plans (now America's Health Insurance Plans [AHIP]).

    Court of Federal Claims Grants Class Action Status in CSR Case

    April 26, 2018 12:01 PM by billupsj

    Judge Margaret Sweeney, of the Court of Federal Claims, has granted Common Ground Healthcare Cooperative’s motion to certify a class in their lawsuit against the United States for cost-sharing reduction payments (“CSR”).  Common Ground is seeking to recover, for itself and other members of the class, CSR payments since October 2017. On October 12, 2017, the Trump administration announced they would no longer make CSR payments to issuers.  Issuers of qualified health plans are required to provide CSR to eligible insureds under section 1402 of the Affordable Care Act.  While acknowledging the issue has not been fully briefed, Judge Sweeney noted that the government did not identify a statutory provision that would support an argument that increased premium tax credit payments offset insurer losses following the cessation of CSR payments.  The government must provide a list of potential class members no later than May 18, 2018. The certified class consists of all persons or entities that offered QHPs during the 2017 or 2018 benefit year that provided CSR payments for eligible insureds.

    FDA Employs Innovative Methods to Prevent Illegal Products from Entering US

    April 26, 2018 11:58 AM by billupsj

    US International Mail Facilities (IMFs) receive 275 million packages a year. One of the FDA’s important public health functions is to closely monitor the FDA-regulated products arriving at the IMFs every day to prevent unsafe, counterfeit, and unapproved products from entering the country. One tool that FDA has deployed is advanced screening technologies that can allow FDA inspectors to screen packages containing suspected drug products more efficiently and reliably.

    Miami Man Sentenced to 8 Years in Prison for Role in Fraud Scheme

    April 26, 2018 11:57 AM by billupsj

    For his part in a health care fraud scheme, Vladimir Prado, a 52 year old Miami, Florida resident, was sentenced to 97 months in prison on April 20, 2018.  The scheme involved a now-defunct home health clinic and two sham physical rehabilitation clinics located in South Florida.  In addition to prison time, Prado is required to serve three years of supervised release following his release from prison, and to pay restitution of more than $4 million.  Prado’s clinic has submitted claims admitted to be false of more than $5 million. 

    FDA Pushes Creation of Cybersecurity Team

    April 26, 2018 11:49 AM by billupsj

    FDA released the “Medical Device Safety Action Plan," outlining five focus areas of the agency on medical device security.  One proposal by the FDA to enhance public safety of medical devices is to develop a team of experts that could investigate cybersecurity incidents involving medical devices. This would be a public-private partnership that would complement existing device vulnerability coordination and response mechanisms and serve as a resource for device makers and FDA. Its functions would include assessing vulnerabilities, evaluating patient safety risks, adjudicating disputes, assessing proposed mitigations, serving in a consultative role to organizations navigating the coordinated disclosure process, and serving as a “go-team” that could be deployed in the field to investigate a suspected or confirmed device compromise at a manufacturer’s or FDA’s request.


    CMS Proposes Changes to Meaningful Use Program

    April 26, 2018 11:48 AM by billupsj

    On April 24, 2018, CMS released the proposed inpatient prospective payment system (IPPS) and Long Term Acute Care Hospital (LTCH) rule for FY 2019 and proposed changes in the implementation of electronic health records (EHRs) systems.  CMS is renaming the Meaningful Use program to "Promoting Interoperability Program," emphasizing the purpose of the program to exchange health information between providers and patients. The IPPS-LTCH rule reiterates the requirement that providers use the 2015 Edition of Certified EHR Technology (CEHRT) in 2019.  CMS announced that it is changing the EHR incentive program to make the program more flexible and less burdensome; emphasize measures that require the exchange of health information; and incentivize providers to make it easier for patients to obtain their medical records electronically. CMS is requesting feedback through a Request for Information on how to revise the Medicare Conditions of Participation to promote interoperability and increase health data exchange between hospitals. CMS is also proposing that EHR reporting periods in 2019 and 2020 for new and returning participants would be a minimum of any continuous 90-day period within each of the calendar years 2019 and 2020.  The reporting period for the new program would be one, self‑selected calendar quarter of CY 2019 data, reporting on at least four self-selected clinical quality measures (CQMs) from the set of 16. Beginning with the 2020 reporting period, CMS is proposing to remove eight of the 16 CQMs.


    Fresenius Medical Care To Sell Sound Inpatient Physician Holdings

    April 26, 2018 11:46 AM by billupsj

    Fresenius Medical Care, the world’s largest provider of dialysis products and services, signed a definitive agreement to sell its controlling interest in Sound Inpatient Physician Holdings (Sound) to an investment group led by Summit Partners for $2.15 billion.  Closing of the transaction is expected in late 2018. Sound is a physician services organization offering a broad spectrum of services including emergency medicine, critical care, hospital medicine, and transitional care, with revenues of over $1 billion in 2017.

    Nomination Slate for Officers and Council Members for FY 2019

    April 23, 2018 3:13 PM by carsons

    The ABA Health Law Section Nominating Committee is pleased to announce the slate of candidates for Officers and Council members for FY 2019:

    VICE-CHAIR (1-year term with automatic ascension to Chair-Elect and Chair)

    • Hal Katz, Husch Blackwell LLP Austin, TX


    SECRETARY (1-year term)




    COUNCIL MEMBERS-AT-LARGE (3-year terms ending 2020)


    Automatic Ascension:

    CHAIR (1-year term beginning August 2018)


    CHAIR-ELECT (1-year term beginning August 2018)


    BUDGET OFFICER (3-year term beginning August 2018)


    IMMEDIATE PAST CHAIR (1-year term beginning August 2018)


    Per Article VI, Section 1 of the Health Law Section Bylaws, notice is hereby given to the members of the Health Law Section. The election of such Officers and Council will occur at the Section Business Meeting during the ABA Annual Meeting in Chicago in August.

    W. Thomas Smith Receives the Champion of Diversity and Inclusion Award

    April 23, 2018 10:45 AM by carsons

    The Health Law Section is pleased to announce W. Thomas Smith as the recipient of this year’s Champion of Diversity and Inclusion Award. The award honors an ABA Health Law Section member who has made exceptional efforts to promote diversity and inclu­sion within the Section and/or the legal profession. Mr. Smith is a Dean of Pharmacy at the Manchester University College of Pharmacy in Fort Wayne, Indiana. The award was presented to him on February 21, 2018 at the Section’s Emerging Issues Conference in Scottsdale by Diversity Committee Chair Tiffany Santos. Adrienne Dresevic and Clinton Mikel of the Health Law Partners in Farmington Hills, Michigan, nominated Mr. Smith for the award.

    Medicare Part E for All Proposed But Passage Remains Uncertain

    April 20, 2018 11:32 AM by billupsj

    Since the Fall of 2017, the Trump Administration has used its executive and regulatory authority to roll back coverage requirements for ACA health plans and expand access to association health plans that would be offered outside of ACA's exchanges to small businesses and self-employed individuals.  In response to the Administration’s efforts to diminish the ACA, which include repealing the individual mandate penalty in the Tax Cuts and Jobs Act, Congressional Democrats, on April 18, 2018, released the Choose Medicare Act, a legislative proposal that would permit, but not require, non-Medicare age individuals and businesses to opt into health insurance coverage offered under a new Medicare Part E program financed by premium payments just as private insurance is today.  The Choose Medicare Act would not replace ACA exchange plans.  Instead, new Medicare Part E plans would be offered on the ACA exchanges alongside other private exchange plan options.

    The Choose Medicare Act is intended to build on ACA’s protections, key features are:

    •  Make available new Medicare Part E plans to individuals of all ages in all fifty states;

    •  Opens Medicare to allow all employers to purchase health coverage for employees without replacing employment-based health insurance;

    • Provide employees an option to choose Medicare Part E over their employer offered coverage;

    • Mandate coverage of essential health benefits plus all items and services covered by Medicare;

    • Increases the generosity of premium tax credits and extends eligibility of these credits to middle-income earners; and

    • Allow Medicare to negotiate prices for prescription drugs (a proposal that enjoys bipartisan support as well as support from the Trump Administration).

    The Choose Medicare Act is the fifth Democratic proposal to support the ACA as some concerns remain regarding the long-term viability of the ACA’s exchange plans without legislation or Trump Administration initiatives to stabilize the exchange marketplace.  Despite the Choose Medicare Act’s focus on freedom of choice over the mandate-laden ACA – an approach which might garner some bipartisan support – the general consensus is this latest legislative proposal has little chance of passage by the current Congress and enactment into law.


    Healthcare Litigation & Risk Management Tweet Chat April 25

    April 20, 2018 9:56 AM by billupsj

    Join the Section for a Tweet Chat on the Pros and Cons of Litigation, Arbitration and Mediation

    Have you always wondered if arbitration and/or mediation would benefit your practice? Join the Health Law Section for a tweet chat, moderated by the Healthcare Litigation & Risk Management Interest Group, which will occur simultaneously with an open membership call and BrownBag Conversation, "Litigation v. Arbitration v. Mediation: Which is Better, When?" at 12 p.m. CT on April 25. Our informal raconteurs -- David Ellenbogen, David Cook and Tony DiLeo -- have a lot of experience with all three. While the call is taking place, join the conversation on Twitter! The hashtag for the tweet chat will be #HLSChat. The Section's Twitter account is @abahealthlaw. The Interest Group's Twitter Account is @HLSHLRM.

    Share your ideas, thoughts and insights on the following topics:

    - Has the cost of protracted litigation facilitated the rise of mediation and arbitration? Is money the only factor? #HLSChat

    - What are the differences between arbitration and mediation? #HLSChat

    - Are there certain circumstances when mediation should be used instead of arbitration, and vice versa? #HLSChat

    - Are there still matters where litigation is the preferred route to resolution, rather than mediation/arbitration? #HLSChat

    - As practitioners, is it incumbent on us to use mediation/arbitration more frequently, to ease the stress on our courts? #HLSChat


    Pennsylvania Adds Treatment for Opioid Withdrawal to State Medical Marijuana Program

    April 19, 2018 3:49 PM by billupsj

    Following New Jersey’s lead, Pennsylvania has approved adding the treatment of opioid withdrawal to be added to the list of approved uses for the state's medical marijuana program. By adding opioid withdrawal to this list, Pennsylvania's Secretary of Health is hopeful there will be increased clinical research in both marijuana and opioids at state health systems.

    Senate HELP Committee Continues Work on Opioid Epidemic

    April 19, 2018 3:47 PM by billupsj

    The Senate HELP Committee introduced the Opioid Crisis Response Act of 2018 (“OCRA”), which includes 40 wide ranging proposals aimed at curbing the opioid epidemic. The OCRA puts a focus on leveraging certain technology tools, such as EHR, telemedicine and prescription drug monitoring programs, in tracking and flagging suspicious controlled substances prescriptions. The bill also calls for increased educational efforts and training programs, including those for first responders to improve treatment of cases involving fentanyl overdoses.

    CMS Issues Final Rule for CY 2019 with Policy and Technical Changes to CARA

    April 19, 2018 3:45 PM by billupsj

    On April 16, 2018, CMS issued a final rule, which is effective as of June 15, 2018, to implement certain provisions of the Comprehensive Addiction and Recovery Act of 2016 (CARA). CARA enacted to address the opioid epidemic, has empowered CMS to create a framework for the establishment of new drug management procedures. To implement CARA, CMS has included a provision that creates a lock-in status for certain at-risk beneficiaries, protecting the safety of these beneficiaries by limiting coverage to specific pharmacies. While an estimated $19 million reduction in 2019 and $20 million reduction in 2023 in Trust Fund expenditures is expected, the cost of this provision to the industry is estimated at $2.8 million per year. CMS also provided provisions to cut costs allowing beneficiaries to opt in to electronic copies of disclosures, saving the industry $54.7 million annually in printing and mailing costs if at least 67% of the current beneficiaries opt-in. The final rule also involves a change in preclusion list requirements for prescribers in Part D and individual entities in Medicare Advantage (MA), Cost Plans, and PACE. Under this rule, prescribers of Part D drugs and providers of MA services and items will no longer be required to enroll in Medicare for coverage. Instead, either a Part D plan sponsor or its pharmacy benefit manager (PBM) will be required to reject the drug if the prescriber is on the preclusion list. Initially the revision will save providers $34.4 million but will cost sponsors or their PBMs $9.3 million. However, in the years following 2019, providers will save nothing and sponsors or their PBMs will incur negligible costs. Finally, physicians will enjoy a $204.6 million annual savings with updated stop-loss insurance requirements that will allow higher deductibles. 

    Coalition asks HHS to Take Action Against ESRD Steering

    April 19, 2018 3:44 PM by billupsj

    A group, comprised of insurance companies, businesses, unions, and consumer groups, sent a letter to HHS asking the agency to take actions against the American Kidney Foundation (AKF).  This informal coalition believes AKF is steering Medicaid and Medicare patients with end stage renal disease (ESRD) to commercial insurance coverage.  The letter alleges that the AKF is providing premium assistance for individuals with ESRD to purchase commercial insurance with the purpose of obtaining higher reimbursements for dialysis centers.  The group cites to a J.P. Morgan analysis finding “that 6,400 Qualified Health Plans purchased through the AKF HIPP program drove an estimated $1.7 billion in adverse selection.“ The AKF responded by noting that charitable assistance allows individuals with kidney failure a choice between private or public coverage.

    Drug Company 'Shenanigans' to Block Generics Come Under Federal Scrutiny

    April 19, 2018 3:42 PM by billupsj

    Trump Administration officials are looking to target branded companies who are not sharing samples of their drugs so that generic versions can be potentially created. FDA Commissioner Gottlieb said that drugmakers must “end these shenanigans”. The FTC is also investigating these practices.

    Former Employee of Southern California Ambulance Company Sentenced to Prison for Involvement in Medicare Fraud Scheme

    April 19, 2018 3:39 PM by billupsj

    Aharon Aron Krkasharyan, former employee of a Southern California ambulance company, pleaded guilty to one count of conspiracy to commit healthcare fraud. Krkasharyan’s actions resulted in more than $1.1 million in fraudulent claims to Medicare and he was sentenced by U.S. District Judge George H. Wu to 36 months in prison. Krkasharyan was also required to pay $484,556 in restitution to Medicare, with other co-conspirators yet to be sentenced.

    DOJ Report: FY 2017 Healthcare Fraud Enforcement Activities Result in $2.6B Recovery

    April 19, 2018 3:37 PM by billupsj

    DOJ and HHS resulted in a recovery of $2.6 billion in taxpayer dollars during FY 2017. Included amongst the most prevalent fraudulent practices uncovered through these efforts in FY 2017 are false claims related to ambulance transportation services, misrepresentations of capabilities by EHR providers, and false claims related to physical and occupational therapy services.

    GAIG and PH&P IG Membership Meeting – Includes a Featured Presentation by Sarah Somers on Medicaid and Work Requirements: The Kentucky Waiver

    April 19, 2018 3:36 PM by billupsj

    The HLS’ Government Attorneys Interest Group (GAIG) and the Public Health and Policy Interest Group (PH&P IG) are hosting a complimentary membership call on Wednesday, April 25, 2018, from 3:00-4:00pm EDT.  To participate, please dial in to 866 646 6488, code: 360 951 4833. This call will provide an opportunity for HLS members to learn more about the GAIG and PH&P IG, as well as the networking and engagement opportunities, educational programs, and other resources offered by these groups.

    In addition to learning more about the GAIG and PH&P IG, those on the call will have the opportunity to hear substantive remarks from Sarah Somers, JD, MPH, managing attorney with the Network for Public Health Law’s Southeastern Region Office/ National Health Law Program.  Ms. Somers’ presentation, entitled Medicaid and Work Requirements: The Kentucky Waiver, will discuss the Section 1115 waiver approved by CMS that will enable Kentucky to require many Medicaid beneficiaries to work in order to receive coverage.  The Section 1115 waiver also imposes premiums on very low income people and introduces other eligibility requirements that previous Administrations had refused to implement.  Advocates quickly sued, arguing that the approval of the Section 1115 waiver violates federal law.  Sarah will provide an overview of the legal and policy background on Section 1115 waivers, discuss the Kentucky waiver, and highlight key details about the lawsuit challenging the waiver.

    OIG Releases Report on Medicare Telehealth Program

    April 19, 2018 3:32 PM by billupsj

    OIG recently released a report finding that almost one third of telemedicine claims sampled did not meet Medicare requirements. OIG found that 31 of the 100 claims examined failed to meet Medicare requirements.  The predominant failure involved beneficiaries receiving, services at non-rural originating sites. OIG estimated that Medicare could have saved $3.7 million in the audit period had the rules been enforced. The OIG audit made the following recommendations to CMS: (1) conduct periodic post-payment reviews, (2) work with contractors to implement all telehealth claim edits, and (3) offer education and training sessions to practitioners on Medicare telehealth requirements.

    Movement on New Federal Bills, Addiction and the Workforce

    April 12, 2018 12:53 PM by billupsj

    The US House and Senate continue to work on bills to address the opioid epidemic and addiction. The House Energy and Commerce Committee concluded a series of hearings addressing the epidemic. The Senate’s H.E.L.P. Committee released a discussion draft of a substantial, multipronged bill called the Opioid Crisis Response Act of 2018 (“OCRA”) and held a hearing on the OCRA on April 11th.  The bill is intended to (i) spur the development of a non-addictive painkiller, (ii) give the FDA authority to require drug manufacturers to package certain opioids for a set duration, (iii) require manufacturers to give patients simple and safe ways to dispose of unused opioids, (iv) improve the detection and seizure of illegal drugs like fentanyl, and (v) improve data sharing so doctors and pharmacies know if patients have a history of substance misuse and states can better track prescriptions. The follow-up to the Comprehensive Addiction and Recovery Act is also on the table.

    The American Action Forum found in a recent study that nearly 1 million people were not working because of opioid addiction in 2015. The number of Americans not in the workforce because they were dependent on opioids grew each year between 1999 and 2015. The cost to the U.S. economy was $702 billion, or just under $44 billion each year.



    Feds Seek to Join Opioid Suit

    April 12, 2018 12:48 PM by billupsj

    The US Dept. of Justice filed a motion requesting to join settlement talks in federal court involving hundreds of lawsuits against manufacturers and distributors of opioid painkillers. The plaintiffs (more than 400 US cities and counties) are requesting repayment for the substantial expenses imposed on them by the opioid epidemic. The historic, multijurisdictional proceeding has brought together hundreds of lawsuits from cities, counties, Native American tribes and unions in a single, massive case presided over by Judge Dan Aaron Polster of the Northern District of Ohio.



    Surgeon General Issues Advisory on Naloxone

    April 12, 2018 12:47 PM by billupsj

    Surgeon General Jerome Adams has issued a rare advisory for Americans to get trained in administering the overdose reversal drug naloxone.  He urges people to talk to their doctors or pharmacists about obtaining naloxone, learn the signs of opioid overdose, and become trained in how to administer naloxone, if needed.

    Hospital Workers' Unions Pushing Proposals to Decrease Dialysis Clinic Reimbursements

    April 12, 2018 12:45 PM by billupsj

    A major hospital workers’ union in California is pushing a ballot initiative to cut off dialysis clinics’ commercial insurance reimbursement at 115% of care costs  which would result in cuts to their current rates. Proponents claim that the initiative may pressure clinics to improve care by increasing staffing and raising their standards in order to bump the cost of care which would result in a higher reimbursement cap. Critics claim the proposal may cause losses for dialysis clinics, hospitals, and state and federal resources. In addition to California, unions in Ohio and Arizona have similar efforts underway.


    Pharmacy Owner and Pharmacist Sentenced to 13 years in Prison for Medication Cream Kickback Scheme Against TRICARE

    April 12, 2018 12:43 PM by billupsj

    Larry Howard, a pharmacist and the owner of Fertility Pharmacy, was sentenced to serve 160 months in prison and ordered to pay $4.3 million in restitution for his role in a kickback scheme. Federal prosecutors say Howard, along with co-defendants Nicole Bramwell and Raymond Stone, entered into an arrangement to funnel patients to doctors pre-selected by Howard. The doctors would prescribe expensive pain medications and scar creams that cost up to $17,000 per bottle.  The medications were billed to TRICARE, and TRICARE, in turn, paid the pharmacy.

    CVS Blames Pharma Rising Drug Prices

    April 12, 2018 12:41 PM by billupsj

    A CVS Health Corp. report, as well as a similar study from Express Scripts Holding Co. earlier this year, highlight the ongoing battle between pharmacy benefit managers and pharmaceutical manufacturers. While drugmakers cast blame on PBMs for lack of transparency and not passing on rebate savings to patients, PBMs point to high list prices as the driving factor.


    California Sues Sutter Health Alleging Anticompetitive Contracts

    April 12, 2018 12:40 PM by billupsj

    On March 29, 2018, California Attorney General Xavier Becerra filed a civil antitrust action against Sutter Health, one of California’s largest healthcare providers. The state alleges that Sutter imposes a series of anticompetitive terms in its contracts, including price secrecy terms that prevent disclosure of Sutter’s negotiated rates, all-or-nothing provisions that require health plans to include all Sutter hospitals in their networks, and anti-incentive terms that prevent plans from offering cost or quality-based incentives to direct patients to non-Sutter hospitals. If the state prevails, the case could significantly alter contracts between healthcare groups, health plans and providers in California. This case is also one to watch amid a growing tide of industry consolidation nationwide.