Public Entity’s Determination of Reasonable and Customary Value is Discretionary, Not a Mandatory Duty
The California Court of Appeal recently issued a decision upholding governmental immunity for a public health plan sued by an out-of-network hospital based on implied contract theories. In County of Santa Clara v. Superior Court, 77 Cal. App. 5th 1018 (2022), the court held that
CMS Recently Introduced New Interoperability Mandates for Health Plans That Must be Implemented by July 1, 2021
The CMS Interoperability and Patient Access Rule (“Interoperability Rule”) requires payors to permit third-party applications to retrieve, with the approval and at the direction of a current enrollee certain health care data. 42 C.F.R. §§ 422.119(a), 431.60(a), 457.730(a); 45 C.F.R. § 156.221(a). The
New U.S. Supreme Court Decision May Expand Health Plans’ Ability to Text Members Under the TCPA
The Telephone Consumer Protection Act of 1991 (TCPA) has restricted health plans’ ability to call or send text messages to cell phone numbers. The U.S. Supreme Court’s recent decision in Facebook, Inc. v. Duguid, 141 S. Ct. 1163 (2021) (“Facebook”) eases those restrictions
Department of Health Care Services Seeks Input From Health Plans
The Department of Health Care Services (DHCS) released a Request for Information (RFI) to solicit stakeholder input into the development of a forthcoming Medi-Cal Managed Care Plan Request for Proposal (RFP) and the updated Medi-Cal managed care contract.
The RFI contained two parts. The first is a set of questions
Federal Court ruling confirms that the Health Insurance Provider Fee must be factored into Medicaid capitation rates
In a recent decision, the Fifth Circuit Court of Appeals reversed a United States District Court judgment that would have resulted in Medicaid managed care organizations (MCOs) paying the Affordable Care Act’s (ACA) Health Insurance Provider Fee (HIPF) without having that enormous expense
The FCC’s Declaratory Ruling Exempts COVID-19 Messages
The Telephone Consumer Protection Act (TCPA) establishes various restrictions on the use of calls or text messages, particularly without express consent. The TCPA does, however, include an exemption for “emergency purposes.” In the event there were any question regarding whether the current COVID-19 pandemic qualifies as an emergency under this exemption, the Federal
What Triggers a Force Majeure Provision and Excuses Performance?
According to Merriam-Webster, “force majeure” translates from French as “superior force.” In contracting terms, a “force majeure” clause is an often overlooked provision containing boilerplate language that will very rarely ever be triggered. The clause is intended to allow a party to be relieved of contractual obligations when unforeseen events beyond
Court Rules that California Legislature Intended Medi-Cal Managed Care Plans to Pay
APR-DRG Rates to Out-Of-Network Hospitals for Post-Stabilization Services
A five-year battle against Dignity Health concluded on January 9, 2020 when the Second District Court of Appeal ruled in L.A. Care’s favor. L.A. Care successfully defended the State’s All Patient Refined Diagnosis Related Groups (APR-DRG) payment methodology as the
