Mid-Atlantic Health Law TOPICS

Utilization Review as the Practice of Medicine: Did you know that Ohio's Attorney General recently opined that physicians making utilization review decisions for third-party payors are not "practicing medicine," and therefore are not subject to Ohio's physician licensing board? (It should be noted that the opposite conclusion has been reached in other states.)

Whistleblower Cases: Did you know that whistle blowing private citizens may be unable to pursue qui tam actions under the False Claims Act? Generally, private citizens have been able to sue a health care provider who has allegedly misbilled the government, and to keep a portion of the amount recovered, if the government chooses not to proceed. However, the United States Court of Appeals for the Fifth Circuit recently ruled that the provisions of the False Claims Act allowing such private enforcement are unconstitutional. This ruling creates a split among the federal circuits, and could lead to a Supreme Court decision on this issue.

Physician Bargaining: Did you know that the State of Texas has proposed rules that would implement the Texas law that allows otherwise independent physicians to negotiate fees collectively with HMOs? Under the law, the Texas Attorney General must supervise the bargaining to shield the negotiations from federal antitrust laws.

Medicaid Managed Care Review: Did you know that the Health Care Financing Administration has issued a proposal that would require managed care entities participating in state Medicaid programs to be subject to an external review of their services from both quality and access perspectives? State Medicaid agencies would be required to perform such reviews under these proposed rules, implementing the Balanced Budget Act of 1997.

Medicare Exclusions: Did you know that the Medicare program presently excludes an average of eight providers per day? Additionally, the federal government obtained 401 criminal convictions against providers in its last fiscal year, and filed 541 civil actions against health care providers.

Pharmacy Litigation: Did you know that third-party payors may be allowed to participate in the settlement of litigation against pharmaceutical defendants who allegedly made false advertising claims concerning the superiority of Synthroid®? Under the terms of a proposed settlement, a settlement fund of $45.5 million is to be created.