Today, participation with managed care organizations (MCOs) typically accounts for a majority of a health care provider’s revenue. Central to maximizing that revenue is the participation agreement between the provider and the MCO. Garfunkel Wild has negotiated hundreds of managed care agreements on behalf of health care systems, community hospitals, physician groups, federally qualified health centers, and various other professional, institutional health care providers and provider networks.
Garfunkel Wild has stayed on top of the trends as managed care contracting has moved from fee for service to value based payment arrangements. Our broad experience with managed care contracting helps to ensure that our clients receive the benefit of their bargained contract – to get paid fairly and timely for the services they render. Garfunkel Wild has negotiated some of the largest fee for service agreements and risk compensation arrangements in the region and regularly deals with major commercial MCOs, including United Healthcare, Aetna, Anthem, Horizon BlueCross BlueShield, and CIGNA, as well as Medicare and Medicaid managed care plans including Healthfirst, Humana, Fidelis, Affinity, Molina, Horizon NJ Health, Amerigroup, and Wellcare. MCOs view us as tough negotiators who know the issues and who have earned their respect over the years -- our clients benefit from these good working relationships.
Yet negotiating a solid contract is not the end of the process. Garfunkel Wild supports clients through the implementation process where managed care provides a new payment mechanism, e.g., community based organizations and other providers that render services that encompass social determinants of health. Garfunkel Wild also regularly advises clients with respect to audits and repayment demands by MCOs, often significantly reducing client exposure.
NYS Public Health Law 18-c, a new law set to become effective on October 20, 2024, will prohibit providers from obtaining a patient’s consent to pay for any health care services prior to the patient receiving services.
The U.S. Department of Health and Human Services, Office of Inspector General (the “OIG”) posted an unfavorable Advisory Opinion (24-08) prohibiting a Corporation offering Medicare Advantage (“MA”), MA-Prescription Drug (“PD”), and MA/MA-PD Employer Group Waiver Plans (“EGWPs”) from sharing a percentage of its savings with its covered groups via a gainshare payment (“Payment”).
The Federal Departments of Treasury, Labor, and Health and Human Services released final rules strengthening consumer protections for patients seeking mental health and substance use disorder treatments. Despite 15 years since the enactment of the Mental Health Parity and Addiction Equity Act (MHPAEA), barriers still exist, preventing individuals from receiving adequate coverage for these issues.
On August 7, 2024, the New York State Department of Health’s (DOH) proposed regulations for a new, unified licensure process for Program of All-Inclusive Care for the Elderly (PACE) organizations were published in the New York State Register. The proposed regulations implement New York Public Health Law (PHL) Article 29-EE, which was enacted in 2022. The proposed regulations, if adopted, will impact PACE organizations that are currently operating, as well as entities with pending and future PACE applications.
OIG posted a partially favorable Advisory Opinion (24-05) permitting a biotechnology company to provide transportation, lodging, and payment of associated expenses for certain patients receiving gene therapy treatments for two severe genetic diseases. In the same Advisory Opinion, however, OIG responded unfavorably to the Company’s proposal to subsidize some or all costs related to fertility preservation and storage procedures for these same patients.
The OIG's trend of ensuring access to care in compelling circumstances continued with a recent opinion allowing a pharmaceutical affiliate to refund, waive, or delay payment for a drug treating a rare, fatal pediatric immunodeficiency disorder.
As we reported in a prior alert titled "NY Upends CDPAP Fiscal Intermediary Framework", the New York State (NYS) budget for fiscal year 2025 significantly changed who can be a Fiscal Intermediary (FI) under the state’s Consumer Directed Personal Assistance Program (CDPAP).
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted a favorable Advisory Opinion (24-03) permitting a pharmaceutical manufacturer (Manufacturer) to provide financial assistance to qualified patients undergoing its gene therapy treatment for two severe genetic conditions.
The U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) released its revamped Semiannual Report (SAR) on June 3, 2024. The SAR’s new format focuses on the oversight work OIG completed during the reporting period, and emphasizes how this work directly addresses the Top Management Challenges Facing HHS.
On May 15, 2024, the New York State Department of Health (DOH) announced a pivotal change in its regulations, as it intends to permit health care providers to use telemedicine to conduct patient evaluations before prescribing controlled substances. Prior to the COVID-19 pandemic, DOH required health care providers to perform an initial in-person physical evaluation of patients before prescribing controlled substances.
Garfunkel’s Compliance Webinar Series rolls on with an examination of the 2024 Work Plan published by the New York State Office of Medicaid Inspector General (OMIG).
On Tuesday, April 23, 2024, the Federal Trade Commission (FTC) promulgated a final rule banning most non-compete agreements, in any industry, and is set to become effective 120 days after its publication in the Federal Register (the “Final Rule”).
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted a favorable Advisory Opinion (24-02) permitting a non-profit organization (Non-Profit) to provide financial support to eligible patients with specific rare diseases through assistance programs (Programs) it operates.
This Health Care Compliance webinar session will review HHS-OIG’s recently issued strategic plan for oversight of Medicare Managed Care and discuss the impact these initiatives could have on providers who participate in Medicare Advantage plans.
The United States Department of Health and Human Services (HHS), Office of Inspector General (OIG) recently posted a new educational resource on its website about Single Audits. HHS is the largest grant-making agency in the Federal government, and OIG’s new resource is designed to help key stakeholders understand the scope of Single Audits, as well as improve the overall quality of such audits.
Despite the United States Supreme Court’s finding that the reduction of Medicare reimbursement rates for 340B outpatient drugs was unlawful, Medicare Advantage organizations (“MAOs”) maintain that they have no similar responsibility to make hospitals whole.
The New York State Office of the Medicaid Inspector General (OMIG) recently updated its Self-Disclosure Guidance and Frequently Asked Questions (collectively, “Updates”). These Updates give participating providers and entities additional insight into how to report overpayments involving unresponsive Medicaid Managed Care Organizations (MMCOs) or multiple entities, as well as those that are untimely, have adjusted or voided claims, or lost or damaged records.
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted a favorable Advisory Opinion (23-11) that allows a medical device manufacturer (Manufacturer) to subsidize Medicare cost-sharing obligations as part of a U.S. Food & Drug Administration (FDA)-approved clinical study involving a Category B Investigational Device Exemption.
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted a favorable Advisory Opinion (23-12) that allows a limited liability partnership (the Partnership) consisting of two classes of physician partners to make a one-time, voluntary redemption offer (offer) to individual partners when they reach age 67.
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted a favorable Advisory Opinion (23-15) permitting a consulting company’s (Consultant) proposal to offer gift cards to its current physician practice customers for referring potential new physician practice customers to Consultant. Notably, OIG determined that the proposed arrangement did not implicate the Anti-Kickback Statute (AKS).
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) released a new toolkit to help Medicare Advantage (MA) organizations replicate OIG audit methodologies to detect and correct inaccurate diagnosis codes in their own systems.
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) recently designated oversight of managed care as a “priority area”, and developed a coordinated strategic plan (the Plan) to better align its audits, evaluations, investigations, and enforcement of managed care.
The New York State Office of the Medicaid Inspector General (OMIG) released its 2024 work plan in furtherance of its mission to coordinate and conduct activities to prevent, detect and investigate medical assistance program fraud, waste and abuse, and to recover improperly expended Medicaid funds.
Continuing its year-end reporting blitz, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its Semiannual Report (SAR) to Congress on December 1, 2023.
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) posted two favorable Advisory Opinions (23-09 and 23-10) to allow a licensed offeror of Medicare Supplemental Health Insurance (Medigap Plan) policies and a preferred health organization (PHO) (collectively, “the requestors”) to incentivize Medigap Plan policyholders to seek inpatient care from a hospital within the PHO’s network. Notably, OIG issued these favorable opinions even though the proposed incentives implicated the Anti-Kickback Statute (AKS) and the Beneficiary Inducement Civil Money Penalty (CMP), and there was no applicable exception or safe harbor.
This week, the United States Department of Justice (DOJ) and the United States Department of Health and Human Services (HHS) fulfilled its annual statutory obligation by releasing its jointly-authored Health Care Fraud and Abuse Control Program (HCFAC) Report for Fiscal Year 2022.
The OIG fulfilled its annual statutory obligation by releasing its Top Management and Performance Challenges (TMC) document. Providers should take note because the document provides important insight into the specific areas over which HHS (and the OIG) will remain focused.
On January 1, 2022, the Federal No Surprises Act (NSA) went into effect to protect patients from surprise bills for out-of-network services but the law’s impact on physicians has been significant. Join us as we walk you through what you need to know about the NSA.
On August 14, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a request for applications for the Making Care Primary (MCP) Model, its newest innovation program aimed at improving patient care by supporting the delivery of advanced primary care services
The final budget for fiscal year 2023-2024 passed this week by the New York State legislature requires certain health care entities to pre-notify the Department of Health (the “Department”) of “material transactions” that meet certain financial thresholds.
Garfunkel Wild's Michael Keane will present at the Healthcare Financial Management Association (HFMA) Metro New York Chapter’s Annual Revenue Cycle Academy, on April 27, 2023.
The No Surprises Act requires providers and facilities to provide uninsured or self-pay individuals with a good faith estimate (“GFE”) of expected charges for a scheduled or requested item or service.
The Office of Inspector General (“OIG”) recently updated its Work Plan to include concerns with: inpatient rehabilitation facilities (“IRF”), a focus on Fraud Referrals with Medicaid Managed Care Plans, and audits on hospital price transparency. Below is a summary of the updates to the Work Plan.
Governor Kathy Hochul re-instated provisions in the State Public Health Law (Sections 2895-b[3] and 2828[1]). The New York State Department of Health (DOH) later notified nursing home administrators that these two provisions are in “full effect” as of April 1, 2022.
Garfunkel Wild’s Debra Silverman and John Martin will present the webinar “Federal No Surprises Act – One month in. What have we learned? What questions remain?" on February 1, 2022, from 12:00 pm – 1:00 pm (EST).
Last year, New York State approved the transition of the Medicaid pharmacy benefit, from managed care (MMC) back to fee-for-service (FFS). The effective date of that transition has been postponed for one month, to May 1, 2021.
Garfunkel Wild Partner/Director Debra A. Silverman and Partner Stacey L. Gulick along with Certified Professional Coder and President of ProCode Compliance Solutions, LLC, Alicia Shickle will present the webinar “COVID-19 Billing for Telemedicine Services and Q&A Session” on March 25, 2020.
New York State’s rapidly evolving response to COVID-19 has resulted in a number of new Executive Orders (“Orders”) from Governor Cuomo, as well as various regulatory waivers and guidance from the Centers for Medicare and Medicaid Services, the New York State Department of Health and other state agencies.
Garfunkel Wild Partner/Director Debra A. Silverman and will be joined by Garfunkel Health Advisors, Inc., President Alicia Shickle to present a complimentary webinar entitled “Resolving Payer Obstacles,” Thursday, August 8, 2019 from 12:00 PM – 1:00 PM EDT.
Debra A. Silverman will present at the New York State Society Of Orthopaedic Surgeons’ Webinar – Understanding Value Based Payments on February 27, 2019.
