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Articles Posted in Health Law

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The results of the 2018 primary election have officially been tabulated and the impact that will be made on healthcare law is slowly becoming clear. The most notable healthcare development is in regards to the Affordable Care Act (ACA) that was enacted in March of 2010 under President Obama, the primary goal of which was to make reasonably priced health insurance available to more Americans than ever before. In recent months, Republicans have been working to repeal and replace the ACA but have thus far been unsuccessful. This most recent election has put that progress back even further. Now, 37 states including the District of Columbia have implemented or are working to implement the ACA’s Medicaid expansion which will increase the coverage of low-income adults who otherwise would not have access to healthcare. This recent growth in the number of states who have adopted the expansion plan may subsequently generate extra pressure for states who have not yet approved the plan.

Incoming Michigan Governor Gretchen Whitmer, who won over her Republican counterpart Bill Schuette, has made it known in the past that she supports the ACA. Whitmer has also recognized that premiums may be considered too high by many and understands something needs to be done to address the cost. In addition, the Michigan Health & Hospital Association (MHA) has plans to work closely with the Whitmer association transition team, ensuring that Michigan’s healthcare needs are fully addressed and that the results are in the public’s best interests. According to the MHA, issues that will be discussed include Healthy Michigan Plan work requirements and rural and behavioral health access, among other topics.

In New York, the departure of former long-time Chair of the Senate Health Committee turned key New York senator Kemp Hannon is causing speculations on whether New York’s political future will include more progressive attention to healthcare law. New York Governor Andrew Cuomo has already made it clear that passing both the Reproductive Health Act as well as the Comprehensive Contraception Coverage Act are going to be some of his first priorities. In addition, Senator Andrea Stewart-Cousins and Senator Gustavo Rivera have both made statements supporting a single-payer healthcare system under the New York Health Act.

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On November 1, 2018, the United States District Court for the District of Columbia issued a Memorandum Opinion, ordering the Medicare appeals backlog to be eliminated by FY 2022.

Specifically, the court ordered that the Department of Health and Human Services (HHS) achieve the following reductions from the current backlog of 426,594 pending appeals:

– 19 percent reduction by the end of FY 2019

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In the FY 2015 IPPS/LTCH proposed rule (79 FR 28169) and final rule (79 FR 50146), CMS discussed and then implemented Section 2718(e) of the Public Health Service Act, which was enacted as part of the Affordable Care Act. The rule aimed to improve the transparency of hospital charges by requiring hospitals to either post standard charges online or to comply with patient requests for such information.

In April 2018, in response to consumer concern and surprise over out-of-network physician services at in-network hospitals, as well as the price of emergency department services, CMS further requested comment on a proposed rule that would require more transparency in hospital pricing. The new rule was officially finalized on August 2, 2018 and requires hospitals to make public a list of their standard charges via the Internet in a machine-readable format, which hospitals must update at least annually. CMS received positive feedback in April from providers and hospitals, and CMS commented in the final rule that this change aligns with American Hospital Association State Transparency Survey data indicating that 35 States already require hospitals to release pricing information for certain charges and that 7 States rely on voluntary disclosure of standard pricing data.

This final rule is a result of a push by the Trump Administration hoping to lower medical costs by encouraging price transparency among medical providers and improve public accessibility to information.  According to CMS Administrator Seema Verma, the Trump administration’s work in this area is just beginning. CMS and the Trump Administration is further encouraging individual states to tackle price transparency via legislation which would allow prospective patients to shop around for the best pricing for future medical services.

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Medicare officials are investigating pharmacies that sell compounding made-to-order gels, lotions, and creams for possible fraud and patient safety risks.  In general, made to order creams used in pain treatments can dramatically improve a patient’s quality of life, but HHS regulators are concerned for patient safety if these drugs are not properly monitored. For example, in 2012, a Massachusetts pharmacy failed to maintain sterile conditions and sold tainted made-to-order injections that killed 64 Americans.  Although State Boards usually regulate these compounded drugs, they are not considered FDA approved.

Medicare officials have identified several target pharmacies allegedly charging extremely high prices, selling large percentages of identical drugs, and that have substantially increased billing for these products.   Price hikes on compounded gels and creams, combined with an increase in dispensed prescriptions, has led to a rise in Medicare spending on pain creams from $13.2 million in 2010 to $323.5 million in 2016.  Regulators are beginning to take measures against pharmacies with suspicious billing patterns, especially in the cities of Detroit, Houston, Los Angeles and New York, all of which have high concentrations of red-flagged pharmacies.

The Health Law Partners frequently counsels compounding pharmacies at a national level on proactive and reactive strategies against fraud and abuse allegations.  For more information on this topic, please contact Adrienne Dresevic, Esq. or Clinton Mikel, Esq. at (248) 996 –8510 or by email at or

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On Thursday, August 2, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released its 2019 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule (the “2019 IPPS Final Rule”).[1]   With the goal to reduce unnecessary administrative burden on physicians and other qualified practitioners, the 2019 IPPS Final Rule revises the requirement that an inpatient hospital admission order be present in the medical record as a condition of Medicare payment.  Specifically, the 2019 IPPS Final Rule amends the regulations at 42 C.F.R. § 412.3(a) to remove the language stating that a physician order must be present in the medical record and be supported by the physician admission and progress notes in order for the hospital to be paid for the inpatient hospital services under Medicare Part A.  See p. 1390 et seq.

Significantly, CMS made no changes to the 2-midnight rule in its 2019 IPPS Final Rule.  Under the 2-midnight rule (codified at 42 C.F.R. § 412.3), an individual is considered an inpatient if formally admitted as an inpatient pursuant to an order for inpatient admission.  Unless an exception applies, an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses 2 midnights.  Therefore, although CMS removed the requirement for an inpatient hospital admission order to be present in the medical record as a condition of payment, an inpatient hospital admission order is still relevant and necessary.  The inpatient hospital admission order reflects the determination by the ordering physician or other qualified practitioner that inpatient hospital services are medically necessary, and it initiates the inpatient hospital admission for the purposes of 2-midnight rule compliance.

For more information, please contact Jessica L. Gustafson, Esq. or Abby Pendleton, Esq. at (248) 996-8510.

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The National Guideline Clearinghouse (NGC) website, “,” compiles the latest information on medical treatment for use by healthcare organizations, physicians, bulk purchasers, educational institutions, and state and local governments, while also providing guidance on medications and procedures ranging from miniscule to critical. The NGC contains over 20 years of evidence-based clinical practices and medical guidelines, and was first created by the Agency for Healthcare Research and Quality (AHRQ) in partnership with the American Medical Association (AMA). AHRQ created the NGC to keep patients safe, develop and track changes to healthcare, and to help doctors and nurses improve the quality of patient care.

Although the database is accessed daily, the operating costs are about $1.2 million per year and with the Trump Administration looking to execute budget cuts, the Department of Health and Human Services (HHS) has decided to delete the database after July 16, 2018. AHRQ officially halted updates to the database and has stopped creating new guideline summaries as of July 2, 2018. AHRQ is receiving expressions of interest from stakeholders interested in carrying on NGC’s work. It is not clear, however, when or if NGC will be available again. AHRQ’s official announcement is available here:

Not only is the future of the database uncertain, but so is the future of the AHRQ. The 2019 fiscal year budget proposed by President Donald Trump would transfer AHRQ’s duties to the National Institutes of Health (NIH), creating a new agency titled the National Institute for Research and Quality. It is unclear whether this new agency will relaunch the database, but at this point there appears to be no plans of another agency or organization taking over or continuing the operation of the NGC. The deletion of the NGC and the elimination of such a vast resource is a major loss to the medical community.

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July 2018- Section 1877 of the Social Security Act, widely known as the physician self-referral law, prohibits a physician from making service referrals payable by Medicare to entities that they may have a financial relationship with. Section 50404 of the Bipartisan Budget Act (“BBA”) of 2018 added provisions to section 1877(h)(1) of the Social Security Act. The added section does not limit an applicable signature requirement to specific exceptions and entities are not restricted to the rule of only once every 3 years with the same referring physician. Moreover, the addition “does not include a reference to the occurrence of referrals or the payment of compensation during the 90 day-period when the signature requirement is not met.”

To be in accordance with the added provision to the Social Security Act, CMS proposed to delete §411.353(g), which is the special rule for certain arrangements involving temporary noncompliance with signature requirements, and instead codify in proposed §411.353(e). Alternatively, CMS has proposed to amend existing §411.353(g) by: “(1) revising the reference at §411.353(g)(1) to specific exceptions and signature requirements; (2) deleting the reference at §411.353(g)(2) to the occurrence of referrals or the payment of compensation during 90-day period when the signature requirement is not met; and (3) deleting the limitation at §411.353(g)(2).”

Public comments on the proposed rules are due by September 10,2018.

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July 2018 – On July 12, 2018, the Centers for Medicare & Medicaid Services (“CMS”) proposed rules aimed at fundamentally improving the nation’s healthcare system and restoring the doctor-patient relationship. The proposal is “one of the most significant reductions in provider burden undertaken by any administration,” according to CMS director Seema Verma. The new proposed rules include the promotion of digital health technology, expanded telemedicine coverage, new documentation requirements, and a newly developed focus on interoperability.

The proposed rules are promoting digital health technology by expanding telemedicine coverage. According to the new rules, CMS will start to pay physicians for virtual check-ins over the phone with their patients to see if the need to come in for an office visit and will also pay them for remote evaluation of images and videos taken by their patients. The intended purpose of this proposed rule is to ameliorate patient concerns in a convenient manner by reducing unnecessary cost to the system with needless office visits.

Moreover, the enactment of the proposed rules would overhaul the current documentation requirements. Instead of having a system with four kinds of documentation requirements, the proposed rules would create a system with one set of documentation requirements that would have four distinct code levels. The overhaul is estimated to save clinicians an estimated 51 hours per year if 40% of their patients are in Medicare. The idea is to have the clinicians documenting material that will capture the patient’s health data rather than spending time typing information to bill a certain level of code.

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June 2018 – On June 19, 2018, the Centers for Medicare & Medicaid Services (“CMS”) issued a Request for Information (“RFI”) seeking public input on how to address any undue impact and burden of the physician self-referral law, 42 U.S.C. § 1395nn (the “Stark Law”).

By way of background, the Stark Law addresses the concern that health care decision making can be unduly influenced by a profit motive and when physicians have a financial incentive to refer patients for health care services, overutilization in medical services may result. To counter such concerns, the Stark Law, subject to certain exceptions: (1) prohibits physicians from making referrals for certain designated health services (“DHS”) payable by Medicare to an entity with which the physician (or an immediate family member) has a financial relationship; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payer) for those referred services.

In response to a prior RFI published by CMS requesting comments on improvements that can be made to the health care delivery system that reduce unnecessary burdens, the commenters identified compliance with the Stark Law and its regulations as one of the top areas of burden. In response to these concerns, CMS is now requesting additional information. Specifically, CMS is interested in thoughts on issues that include the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the Stark Law and terminology related to alternative payment models and the Stark Law.

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Please Join The HLP at the 2018 Physicians Legal Issues Conference in Chicago, Illinois

The Health Law Partners (HLP) is proud to be part of the upcoming Physician Legal Issues Conference co-sponsored by the American Bar Association Health Law Section and Chicago Medical Society.  The conference will take place at the Intercontinental Hotel in Chicago on June 7-9, 2018.  Adrienne Dresevic, Esq., a founding partner of the HLP, is Co-Chairing the conference this year.  Jessica Gustafson, Esq., a founding partner of the HLP, will be a featured speaker at the conference. Ms. Gustafson’s speech is titled, Will Medicare Revoke Your Billing Privileges? Don’t Answer “No” Too Quickly.  Her session addresses key issues for providers and suppliers facing revocation of billing privileges, including: an overview of CMS’s revocation authority, how CMS is using this authority against provider and suppliers, and strategies for appealing revocation.  Attend the conference to learn the latest on health reform, payor alignment, clinical integration, healthcare employment and other issues that impact the legal profession. Programming includes topics such as: Stark Law, Health Reform, Anti-Kickback, and more!

To the view the brochure with program details please click here.  To register for the conference please click here.

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