Justice Department joins lawsuit against Prime Healthcare

http://www.healthcaredive.com/news/justice-department-joins-lawsuit-against-prime-healthcare/419849/

Judges Gavel

The U.S. Justice Department recently filed notice in U.S. District Court in Los Angeles that it is partly intervening in a whistle-blower case against Prime Healthcare Services. The whistle-blower lawsuit alleges that Prime Healthcare fraudulently billed Medicare for beneficiaries admitted as inpatients instead of treating them as outpatients.

http://www.healthcaredive.com/news/doj-accuses-prime-of-driving-up-medicare-admissions/421800/

GA, CA Hospitals Sue Blue Cross Plan for Sending ER Reimbursements To Patients

http://www.healthleadersmedia.com/finance/ga-ca-hospitals-sue-blue-cross-plan-sending-er-reimbursements-patients?spMailingID=9138342&spUserID=MTMyMzQyMDQxMTkyS0&spJobID=942934540&spReportId=OTQyOTM0NTQwS0

Hospital Lawsuit

That’s costing the hospitals money since patients don’t always turn over the funds, according to the lawsuits, filed by Polk Medical Center in northwest Georgia and Martin Luther King, Jr. Community Hospital in Los Angeles.

Judge sides with hospitals over California ballot initiative to cap executive pay

http://www.mercurynews.com/elections/ci_30057620/judge-sides-hospitals-over-california-ballot-initiative-cap

Executive Compensation

 

It’s NC Hospitals vs. Koch Brothers in CON Battle

http://www.healthleadersmedia.com/community-rural/its-nc-hospitals-vs-koch-brothers-con-battle?spMailingID=9138342&spUserID=MTMyMzQyMDQxMTkyS0&spJobID=942934540&spReportId=OTQyOTM0NTQwS0

Koch Brothers

The push to eradicate certificate of need statues in several states is spearheaded by a political advocacy group that claims a repeal of the regulations would “lower healthcare costs and improve medical access for millions of citizens.”

CDC reveals Americans are going to the ED more than you think

http://www.healthcaredive.com/news/cdc-reveals-americans-are-going-to-the-ed-more-than-you-think/421560/

https://www.cdc.gov/nchs/products/databriefs/db252.htm

Health policy leaders to HHS: More bundled payment models, please

http://www.healthcaredive.com/news/health-policy-leaders-to-hhs-more-bundled-payment-models-please/421562/

  • The Center for American Progress (CAP) and other health policy leaders issued a joint letter to HHS Secretary Sylvia Burwell advocating further advancement in Medicare payment reform.
  • The signatories seek additional mandatory bundled payment demonstrations, arguing they would show stakeholders — including hospitals, physicians, device manufacturers, skilled nursing facilities, and home healthcare agencies — that aggressive expansion is coming for bundled payments and other payment reforms.
  • CAP has long advocated for Medicare to expand its most successful bundled payment models, including its Acute Care Episode demonstration project.

Click to access Mandatory-bundled-payment-letter.pdf

4 forces that will influence medical cost trends in 2017

http://www.healthcaredive.com/news/4-forces-that-will-influence-medical-cost-trends-in-2017/421162/

Binoculars

The healthcare industry is in a transformational period. The rising use of retail clinics, MACRA, population health efforts and the Medicare Part B demonstration are but a few examples of disruptive conversations being had in board rooms. Yet, all of these discussions are underscored by the one topic underlying most business conversations: the almighty dollar.

There’s a push and pull between healthcare services utilization and narrow networks focusing on value that could shift the medical cost growth rate in future years. “When medical growth outpaces general inflation, a flat trend is not good enough,” the report states.

“As a result, 2017 will be a tough balancing act for the health industry,” the report states, adding, “Healthcare organizations must simultaneously increase access to consumer friendly services while decreasing unit cost. Employers, worried that this current trend is at an inflection point that could turn back up, will demand more value from the health industry.”

Supreme Court upholds implied certification theory under the FCA

http://www.healthcaredive.com/news/supreme-court-upholds-implied-certification-theory-under-the-fca/421383/

Supreme Court6

In its decision, the Court addressed two major issues. Of greatest significance, it approved an “implied false certification theory of liability” in FCA cases. “The law now treats a provider’s payment request as an implied certification of compliance with all relevant statutes, regulations, or contract requirements, says Brian Mahany, a healthcare fraud expert and whistleblower claims lawyer.

What’s more significant is that for the first time, the Supreme Court imposed real limitations on implied certification. Based on the Court’s decision, for a claim to be considered false or fraudulent under the implied certification theory,” the regulation or contractual provision impliedly violated be must be “material” to the government’s payment decision. “In so holding, the court plainly rejected the government’s more expansive reading of the law,” says Kalb.

Oregon P4P efforts paying off, net $168M in incentives

http://www.healthcaredive.com/news/oregon-p4p-efforts-paying-off-net-168m-in-incentives/421531/

http://www.oregon.gov/oha/news/Pages/Oregon%20Health%20Authority%20releases%20the%20fourth%20CCO%20Metrics%20Report.aspx

Today the Oregon Health Authority released its fourth annual Coordinated Care Organization (CCO) Metrics Report. The report details CCO performance on a variety of quality measures, and shows the incentive payments the 16 health plans will receive based on each plan’s results in serving Oregon Health Plan (OHP) members. For 2015, CCOs received a combined total of $168 million in incentive payments. These pay-for-performance funds mark a continued movement toward paying for quality and access to care—not just services delivered—in Oregon’s health care system.