Emerald Coast Medical Association is dedicated to keeping our members up to date on any legal changes going on in the medical community. The most recent one being a massive package of measures in response to the ongoing opioid crisis. This package includes over 70 bills, each of which makes a significant impact on how the opioid crisis is handled.
The package was passed with the majority of Senators voting yes and only one Senator voting no. This bill will go on to the House of Representatives before advancing on to President Donald Trump. The House of Representatives had previously passed a similar package, so this one should go through with little trouble. One Senator, Lamar Alexander, described opioids as being the “most serious public health epidemic.” This statement further proved to the rest of the Senate the importance of this package of bills.
One bill included in the package is the STOP Act, which is put in place to stop illegal drugs at the border. Another is Jessie’s law; this bill was named after a Michigan woman that overdosed on opioids and died. Jessie’s law ensures that doctors can access patients’ prior addiction history, with consent, so that they can make informed decisions when treating an addict.
A bill called the Patient Right to Know Act had strong support from Senator Alexander. Certain contracts bar pharmacists from informing patients when their insurance causes a prescription to cost more than if they paid for it out of their pocket. This bill voids these contracts and allows pharmacists to make patients aware of when they are in this situation.
This package of bills would provide various benefits and an added layer of protection to Americans everywhere. Banning pharmacy gag clauses will benefit many people, patients, and pharmacists alone. As of right now, this package of bills is moving up to The House of Representatives and is expected to make it even further. There are far more bills listed in the package than just the ones mentioned in this article. Find the full list here.
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The medical community has its own laws that can be changed. Often, these laws have a significant impact on the medical community and the way patients or physicians are handled. At Emerald Coast Medical Association, we strive to keep our members up to date on even the smallest of legal changes.
Recently, Medicare Advantage insurers had a legal victory when a judge ruled that payers no longer have to report and return overpayments. According to the judge, the rule “violates the statutory mandate of ‘actuarial equivalence’ and constitutes a departure from prior policy that the government fails adequately to explain.” The previous law stated that any incorrect diagnostic code that was not documented in a patient’s chart could be classified as an overpayment.
More or less, the effect of the 2014 Overpayment Rule is that Medicare Advantage insurers are paid less to provide the same health care coverage that CMS pays for comparable patients. The 2014 ruling has now been overturned, which is a big deal for those in the medical field everywhere.
Currently, there is an ongoing fraud case against UnitedHealth. They have had numerous fraud cases against them, stemming from the government alleging the insurer submitted incorrect diagnosis codes even though they knew they were wrong. The new ruling will help stop fraud from happening, which will, in turn, benefit medical professionals and patients everywhere.
Emerald Coast Medical Association is proud to say that we can keep our members up to date on legal changes. This new ruling will significantly impact patients and physicians everywhere. If you haven’t already, join us at our next member meeting for no charge, no strings attached.
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Tuesday, September 4th marked a big moment for providers in the Affordable Care Act, when Montana Health Co-op was awarded a win in the ongoing battle between insurers and the government over cost-sharing reduction payments (CSRs). The health cooperative, which serves about 50,000 members throughout Idaho and Montana, filed suit against the federal government in January, claiming it was owed approximately $5 million in CSRs for 2017.
U.S. Court of Federal Appeals Judge Elaine Kaplan agreed, ruling that the government had failed to fulfill its obligation under the ACA when it halted the payouts in October 2017. In making her decision, she specifically referred to the sentence in the ACA that states: “An issuer of a qualified health plan making reductions under this subsection shall notify the Secretary of such reductions and the Secretary shall make periodic and timely payments to the issuer equal to the value of the reductions.”
In 2014, during the Obama administration, the Department of Health and Human Services began making CSR payments to insurers to help low-income Americans pay for their policies under the ACA. Later that year, Republicans in the House of Representatives sued the Administration, saying they and others in Congress had never signed off on the necessary funds to make these payments. They won, and a subsequent appeal was tabled due to the election of Donald Trump.
Trump-appointed Attorney General, Jeff Sessions, issued an opinion in 2017 that the funds were never appropriated, so the payments were halted by the government. Unfortunately, while this meant the insurers no longer received these monies, they were still required by the ACA to offer the same low out-of-pocket costs to patients who were qualified. Naturally, this led to an outcry from payer organizations and had led to a flurry of lawsuits from health plans and cooperatives, attempting to recoup the lost funds.
Common Ground Healthcare and Sanford Health Plan, two of the six payer organizations that still have cases working their way through the judicial system, should be pleased about the Montana Health verdict, though even with a ruling in their favor, the Department of Justice could appeal. In that case, the appeal would be tried by the Federal Circuit Court of Appeals, the same court which ruled earlier this year that HHS did not have to make risk corridor payments to Moda Health, or to any ACA insurers, in a reversal of a 2017 ruling brought by the Court of Federal Claims.
However, that ruling hinged on the presence of a Congressional appropriations rider, a factor not present in the Montana Health case. Karen Early, the director of operations, says the company is pleased with the judge’s ruling, adding that the CSR money helped keep services affordable for their members. “These are funds that do not benefit the health insurance company.” she said on Thursday, “The cost-sharing reduction funds are just benefit money that is passed through the health insurance company to offset the costs of benefits for folks with lower incomes.”
Emerald Coast Medical Association will continue to monitor the legislation and trials regarding changes to the ACA and its benefits. We are committed to keeping our valued members informed and up to date. If you are not a member, we encourage you to attend a monthly meeting, free of charge, to find out how a strong alliance can help you accomplish more as physicians and also to grow and expand your horizons outside of work.