Health Care Law Blog
On Tuesday, August 18, the Michigan Department of Insurance and Financial Services (“DIFS”) announced that it has approved health insurance rate increases that average 6.5 percent for the individual market and 1 percent for the small group market.
Each year, DIFS is responsible for reviewing rate changes proposed by health insurers to determine whether such changes comply with state and federal laws. As part of its review this year, DIFS considered public comments that were submitted after the requested rate changes were posted. DIFS approved all rate changes as requested after determining that such changes were actuarially supported.
In a first-of-its-kind and closely followed case, a U.S. district court denied a New York health system's (Healthfirst’s) motion to dismiss the U.S. government's and State of New York's complaints in intervention under the federal False Claims Act (FCA) and New York state counterpart. This case represents the first time that the government has intervened in an FCA case based upon an allegation that a party violated the "60 day rule." The 60 day rule came into existence with the passage of the Affordable Care Act (ACA) in 2010 and subjects parties to FCA liability for failing to report and refund an overpayment within 60 days of identification, even if the defendant received the payment through no fault of its own.
The case, Kane ex rel. United States et al. v. Healthfirst et al., involves three hospitals that were part of the Healthfirst health system network and provided care to patients that were part of Healthfirst's Medicaid managed care plan. Healthfirst received payments from the New York State Department of Health (DOH) in return for services provided to Medicaid eligible enrollees.
The government's allegations stem from overpayments to Healthfirst as a result of a software glitch. Healthfirst was first questioned about the possible overpayments by the New York State Comptroller's office in 2010. The health system tasked Kane, an employee and the eventual whistleblower in the case, to look into the payments. Five months later Kane emailed Healthfirst management a spreadsheet listing over 900 claims totaling more than $1 million that contained an erroneous billing code that may have led to the overpayments.
The U.S. Department of Justice (“DOJ”), together with the Michigan Attorney General (“AG”), recently filed a lawsuit alleging that four hospital systems located in Southern Michigan violated antitrust laws by agreeing not to compete with one another.
The civil lawsuit was filed in the U.S. District Court for the Eastern District of Michigan and alleged that the four hospitals agreed not to market or advertise themselves in each others’ territories, which constitutes “unreasonable restraints of trade that are per se illegal” under the Sherman Act and the Michigan Antitrust Reform Act.
Talk about adding insult to injury. A Virginia man woke up after his colonoscopy to learn that the surgical team had mocked, belittled and insulted him throughout the procedure.
Fearful that he would not remember the doctor’s post-op instructions, the man pressed record on his smartphone before receiving anesthesia. Upon listening to the recording after the procedure, he realized that the members of the surgical team began their rant as soon as he drifted off to sleep.
