Recent Posts

  • The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Plans
    March 11, 2024
    By: Andrew Silverio, Esq. It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”  At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, ...
  • How the Recent Industry Cyberattack Impacts You
    March 7, 2024
    By: David Ostrowsky Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a ...
  • Millions Saying Good-Bye to Medicaid
    February 22, 2024
    By: David Ostrowsky That millions of Americans have been losing Medicaid coverage over the past year may be unsurprising, but it doesn’t make it any less heartbreaking. Some historical context: Normally, Medicaid recipients who receive federally funded health insurance due to disabilities or low incomes undergo eligibility reviews every year to see if they are eligible for renewed coverage. But, of course, March 2020 was far from a normal time and the feds froze the checks due to it being a public health emergency. Subsequently, Medicaid recipients would retain their enrollment for the following three years . . . until ...
  • Welcome to the Subrogation Sphere
    February 9, 2024
    By: Cindy Merrell, Esq. The Subrogation Sphere Is a Place Where Opponents Become Allies   Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the ...
  • Are Measles Making a Comeback?
    January 31, 2024
    By: David Ostrowsky When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US: “We're going to start seeing more and more of these outbreaks,” Osterholm told USA TODAY last month. “We're going to see more kids seriously ill, hospitalized and even die. And ...
  • A New Year Brings New (Higher) Prescription Drug Prices
    January 18, 2024
    By: David Ostrowsky It must be January. W-2 forms are hitting the mail. Fitness centers are packed to the brim. The NFL playoffs are in full force. And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year, when insurance plans turnover, Big Pharma unveils its list of new (aka elevated) prices for drugs, which, particularly concerning newly launched ones, sparks sticker shock for consumers. Certainly, January 2024 does not appear to be an exception to this unpleasant trend. On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: ...
  • Considerations Regarding the Exclusion of Gender-Affirming Care
    January 16, 2024
    By: Kendall Jackson, Esq. Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act ...
  • Is the Department of Labor Offsetting a Major Problem?
    January 3, 2024
    By: David Ostrowsky As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. The inconvenient truth is that many participants on ERISA self-funded health plans, ones who are often already paying high premiums and deductibles, have unknowingly fallen victim to the ethically questionable – although not technically outlawed -- practice of cross-plan offsetting over the years. In fact, only very recently, as in the past several months, has there been heightened awareness of the adverse effects of cross-plan offsetting on unsuspecting American plan participants. First, a quick primer on cross-plan offsetting: There ...
  • Time’s Up! It’s Gag Clause Attestation Season
    December 26, 2023
    By: Andrew Silverio, Esq. As the year wraps up and plans and TPAs around the country are scrambling to handle renewals, another challenge looms large in 2023 – the first annual gag clause attestation.  As a reminder, the Consolidated Appropriations Act, 2021 (CAA) prohibits plans from entering into any contracts with providers and certain other entities that contain “gag clauses” – and requires them to attest annually that their contracts are free of them. The first attestation is due at the end of 2023, and it will cover the period of December 27, 2021 through December 31, 2023. The goal ...
  • For Sickle Cell Disease Patients, Hope Has Arrived – but at What Cost?
    December 21, 2023
    By: Kelly E. Dempsey, Esq. For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an inherited genetic red blood cell disorder that affects hemoglobin, the protein that carries oxygen throughout the body, torments nearly 100,000 Americans (20 million people worldwide), a disproportionate number of whom are African-American. Among other symptoms, SCD often triggers chronic bouts of excruciating pain that require regular hospitalization, organ failure, strokes, and shortened life expectancy. Meanwhile, the only known cure for the insidious disease has been a bone marrow transplant. Until last month, that is. ...
  • Is Artificial Intelligence the New Frontier for Healthcare?
    December 12, 2023
    By: David Ostrowsky The ills of the American healthcare system, namely an undue administrative burden on healthcare providers and a labor supply not keeping pace with the demand for services, have been well documented. But now, as we grind through the 2020s, relief may be on the way with the booming popularity (or in some cases, acceptance) of artificial intelligence (AI). Many healthcare experts believe that AI – a mechanism grounded in the simulation of human intelligence by computerized systems and one that has already changed how many humans learn and work – could revolutionize the field. But as enticing ...
  • MAHP 2023 Annual Health Care Conference: Health Care Affordability, Quality and Equity in a Post Pandemic World
    November 28, 2023
    By: David Ostrowsky A year later … and how (relatively) little has changed in the state of Massachusetts healthcare. Last November, the Massachusetts Association of Health Plans (MAHP) Annual Conference focused on healthcare challenges and opportunities – both from a regional and national perspective -- amidst a receding pandemic. The 2022 conference, headlined by then-Governor Charlie Baker, homed in on two topics: a.) healthcare equity and b.) regulation of provider prices. Twelve months later, on November 17, 2023, the MAHP 2023 Annual Conference, held once again at the Seaport Hotel in downtown Boston, had an eerily familiar theme: “Health ...
  • Minor Members and Third Party Settlements
    November 27, 2023
    By: Cindy Merrell, Esq. Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? The answer is yes. However, there are various factors that can influence the Plan’s recovery in these circumstances. Federal courts across the country have recently considered a few challenges to a health plan’s right of recovery and clarified an ERISA plan’s right of recovery through reimbursement. What is abundantly clear is good plan language is vital to a health plan’s recovery. Who? What? When? Where? Any subrogation professional is aware that good plan language is important to a plan’s successful ...
  • Being Mindful of Telemedicine Access
    November 9, 2023
    By Jen McCormick, Esq. and David Ostrowsky From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, the practice of providing medical and mental health services remotely, and a heightened awareness of many Americans’ longstanding mental health issues. Due to a confluence of prolonged extenuating circumstances, it became readily apparent to healthcare providers, politicians, social workers, employers, teachers, and parents on both sides of the Mississippi that a.) the inimitable convenience of virtual healthcare does not compromise quality (at least for some patients and practitioners) and b.) many Americans ...
  • Update on the Federal IDR Process
    October 27, 2023
    By: Kendall Jackson, Esq. Recently there has been significant discussion about the federal IDR process. The IDR process is an important tool of the No Surprises Act (“NSA”) as it resolves claims for payment for out-of-network items and services. It not only provides a procedure for settling disputed claims but is also an integral mechanism for supporting the NSA’s protection for plan members against potentially crippling expenses from balance billing for high-cost out-of-network claims. In Texas Medical Association v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK (TMA IV), the U.S. District Court for the Eastern District of ...
  • Empowering the 2023 SIIA National Conference
    October 26, 2023
    By: David Ostrowsky Earlier this month, the self-insurance industry’s most prominent thought-leaders, innovative service providers, and esteemed subject matter experts convened at the 2023 Self-Insurance Institute of America (SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference, which this year covered such pressing topics as artificial intelligence, surprise billing, emerging trends impacting the employer stop-loss market, and recent legislative and regulatory updates, is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (there were over 950 booths representing industry vendors stationed in ...
  • District Court Strikes a Blow to Copay Accumulator Programs
    October 11, 2023
    By: Andrew Silverio, Esq. Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums.  Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers.  The Trump Administration’s Notice of Benefit and Payment Parameters for 2021 (“NBPP”) facilitated these programs by explicitly permitting plans to not count manufacturer assistance amounts toward annual deductibles or out of pocket maximums.  ...
  • Fall Is Here & So Are the Cold-Weather Germs – New CDC Recommendations
    September 26, 2023
    By: Kelly Dempsey, Esq. Fall is officially here as the fall equinox has passed and with fall comes the impending “flu season” which also brings a bunch of other germs – new strains of COVID-19 and a rise in RSV cases. If you have children who have headed back to school (even college kids), you’ve probably noticed an uptick in stuffy noses and tummy aches already. In anticipation of the upcoming turn in weather that brings an increase in viral illnesses, the Centers for Disease Control and Prevention (CDC) has been busy issuing new recommendations related to RSV – formally known ...
  • Three Shots for Autumn
    September 18, 2023
    By: David Ostrowsky It’s a daunting Venn diagram – the interplay of three potentially fatal diseases: Respiratory Syncytial Virus (“RSV”), COVID-19, and influenza. And with summer slipping into fall, this triple-headed monster is (once again) threatening to rear its ugly head. But, thanks to modern medicine, could this cold-weather season have a less devastating toll on humanity than what transpired a year ago? As has been well publicized this past week, there is in fact reason for optimism as updated COVID-19 vaccines from Pfizer and Moderna targeting the devilish Omicron variant XBB.1.5 will soon hit the market. It’s a promising development ...
  • The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations
    August 30, 2023
    By: David Ostrowsky Traditionally, August is a slow news month. Congress is on recess; dignitaries have ensconced themselves in their summer homes; many reporters are on vacation. Invariably, the waning days of summer don’t appear conducive to delivering breaking news. Not this year, however. Indeed, August 2023 will go down as a momentous period of time in American history. A month that was dominated by headlines involving criminal charges brought against former President Donald Trump ended with a healthcare development that will surely impact an untold number of Americans for the foreseeable future. On August 29, President Biden unveiled the first ten ...
  • Protecting the Most Vulnerable
    August 24, 2023
    By: Corey Crigger, Esq. In February 2022, we received a balance bill referral that was truly exceptional, but for all the wrong reasons. Our client received a staggering bill of over $675,000.00 after a premature delivery with major complications resulted in a two-month stay in the NICU. It was an unjust financial burden exacerbating an already challenging situation. Our Efforts to Help: We immediately sprang into action, aiming to halt collection efforts while devising a strategy to achieve desired results. While the provider was unwavering in their stance, our #PatientDefenseProgram Partner Firm came to our aid. After over a year ...
  • Wegovy: The Heart of the Matter
    August 18, 2023
    By: David Ostrowsky Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment? On August 8, Novo Nordisk, the Danish pharmaceutical juggernaut, unveiled the intriguing results of a large-scale clinical study documenting the efficacy of its obesity drug called Wegovy: of ...
  • The Power Dynamics of Gag Clauses
    August 14, 2023
    By: Jon Jablon, Esq. In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights ...