In the national debate over health insurance, the Affordable Care Act gets the spotlight. However, most Americans don’t get their health insurance on the ACA's exchanges. They have insurance through their employers.
The US Department of Justice (DOJ) recently joined a federal qui tam lawsuit1 brought against a private equity firm that specializes in health care pharmacies. Notably, the case also charges individual partners of the private equity firm, Riordan, Lewis & Haden, Inc. (RLH) based in Los Angeles2. They are charged with violations of the federal Anti-Kickback Statute (AKS) and the federal False Claims Act (FCA) in connection with their management of Diabetic Care Rx/Patient Care America (PCA), a compounding pharmacy. The case involves reimbursements from TRICARE, the health care program for the military and their families.
Health care fraud and abuse cases are often won or lost on the effective use of expert witnesses. As health care fraud cases have become more complex and technical, the scope and use of expert testimony has proliferated, and the successful use of experts is one of the lawyer's most important jobs. False Claims Act, Anti-Kickback Statute, and Stark Law cases all demand various types of experts to assist the trier of fact in understanding the nature of the case, the morass of rules at play, the evidence, and a variety of billing, valuation, contractual, technical, and compliance concepts. Increasingly, expert reports and testimony play a pivotal role in motions for summary judgment, as well as at trial. Experts also are used in "conference room litigation," such as mediations or negotiations between defense counsel and enforcement agencies. This article is the result of interviews with health care fraud litigators and expert witnesses in the field who identified their best practices to produce optimum outcomes for their clients.
Population health is not possible in a discounted fee-for-service world, and the significant healthcare business challenge is how to transition from fee-for-service to risk-based capitation in a sustainable way. The following represents an outline for how this transition can be staged so that early steps exploit the benefits of fee-for-service while the latter ones exploit a more capitated model:
Not too long ago, I had the sad task of testifying at a civil litigation and a judicial hearing for two physicians who had been suspended from their respective medical staffs. In both cases, the suspensions and resultant procedural rights were avoidable because proactive communication and management did not effectively take place. Such events should be rare and most medical staffs can easily avoid them by focusing on preventive actions and addressing potential performance issues early in a supportive and assertive manner.
Regulatory hurdles prevent more hospitals from using e-health to its full potential. Federal and state policies and regulations on care rendered via technology from a remote site spin a tangled web for providers either engaged in e-health or who want to be. A February 2014 article in Health Affairs found strong associations between state policies and hospitals' adoption of e-health, also known as tele-health or telemedicine.
The Goldhaber Warnings Report: The U.S. Supreme Court ruling (March 5, Levine vs. Wyeth) will have major implications for the pharmaceutical industry forcing them literally to review all of their warnings and safety instructions for content, clarity and conspicuousness
It started with Joe. My elderly neighbor had lost his wife and his only child lived in New Jersey. He was totally deaf. How could I not help? My children were then young, and we adopted Joe. How could I have known he would become my charge for over five years
Researching and purchasing individual and family health insurance can be a confusing and time-consuming project. This ebook provides several questions to ask yourself and issues to consider prior to beginning your health insurance research