Jay Mark Waxman

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The medical credentialing process, whether for a hospital, a hospital system or a health plan, has emerged as a potential early target for the application of blockchain technology and administration.1 It is a process that allows a secure database to be established over time and on a cumulative basis. Medical credentialing involves verifying whether a candidate meets the applicable educational and training prerequisites for the position sought — appointment to a hospital’s medical staff or the…
Practitioners in the Medicare or Medicaid managed care space place heavy reliance on the protection of the Anti-Kickback Statute (AKS) Safe Harbor found at 42 C.F.R. § 1001.952(t), generally known as the “EMCO [eligible managed care organization] Safe Harbor,” as they look at incentive arrangements between providers and managed care plans. Although the language of the regulation is generally understood, there has not been any guidance from HHS’s Office of the Inspector General (OIG) since…
Just what is reasonable compensation in the Medicare world is not a clearly defined, black and white concept. Instead, it is somewhat in the eye of the beholder, with the parties to each situation where that is an issue seeking to reach out for third party support for their conclusions. But sometimes when the government gets a chance to look at the conclusions, it is a “bridge too far.”…
In our blog post of July 10, 2018, we discussed the key elements of the Final Rule issued on June 21, 2018 with respect to Association Health Plans (AHPs). As we noted, the expansion of ERISA’s definition of an employer and the other elements of the Final Rule designed to expand insurance opportunities for small employers, including sole proprietorships had been opposed by a variety of interests, including the Attorneys General of a number…
There are many health care financial arrangements where one entity has a financial obligation to another, with whom it either does business directly, or to which it makes referrals, and that obligation is either past due or for one reason or another cannot be paid. This may come up, for example, in the context of leases to physicians in a hospital owned medical office building (MOB), a loan made to a physician by a supplier…
Earlier this month, the Department of Labor (DOL) released its Final Rule seeking to expand the scope of participation in Association Health Plans. The Final Rule, titled “Definition of ‘Employer’ under Section 3(5) of ERISA – Association Health Plans”, with a few revisions, codified the Proposed Rule. At its heart is a change to the criteria under ERISA under which employers may join together and be treated as the “employer” sponsor of a single multiple-employer…
After a concerted effort, the bipartisan bill to reform the way care is delivered to Veterans has been signed into law. While there are a number of significant reforms, perhaps none are so critical as those related to the ability of Covered Veterans (the Veteran)  to receive their care outside of the current VA system, and from private health care providers. Through the establishment of the Veterans Community Care Program, a system will be created…
Two recent cases illustrate the continuing challenges providers, and in particular hospital providers, face when seeking to collect their charges when dealing with “out-of-network” patients. First Example – A Claim for Services Under an ERISA Plan In the first, a not for publication decision of the 9th Circuit, Eden Surgical Center v. Cognizant Technology Solutions Corp., et al. [Case No. 16-56422 (9th Cir., April 26, 2018)], the Ninth Circuit in rather abrupt fashion addressed a…
Federal Judge Rosemary Collyer’s May 12, 2016 ruling in House of Representatives v. Burwell, found that the Obama administration (the “Administration”) has been improperly funding an Obamacare subsidy program. House of Representatives v. Burwell involves two sections of The Patient Protection and Affordable Care Act (the “ACA”): Sections 1401 and 1402. Section 1401 provides tax credits to certain individuals to make insurance premiums more affordable, while Section 1402 reduces deductibles, co-pays, and other means…
On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (hereinafter the “Final Rule”). The Final Rule will be codified at 42 C.F.R. Parts 417, 422,…