Parties reached a $1 million settlement in an Eastern District of Michigan class action suit against an insurance company regarding coverage for certain behavioral therapy/treatment for autism. The settlement money will reimburse at least 100 families for the costs of past behavioral therapy, in this case, applied behavioral analysis (or ABA therapy), for their autistic children. Coverage was previously denied on the grounds that the therapy was experimental. However, documents obtained during the litigation revealed that ABA treatment is “currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment, among others.” Going forward, the insurance company will offer insureds the option to purchase coverage for early intervention autism treatment.
Lawyers involved in the litigation believe it may be the first settlement where an insurance company has agreed to provide coverage for such autism treatment and are hopeful that the case will instigate more insurers to follow suit. Moreover, at least 13 states have passed laws requiring insurance companies to pay for autism treatment and screenings, and the news of the settlement may call other state legislatures to action.
You can find a full report on the case in The National Law Journal, which reported the story on June 23.
To read about Wisconsin’s efforts in requiring insurers to cover autism treatment, click here.
The State of Wisconsin has a web site to provide users with an official resource for information about the current spread of swine flu. Go to Wisconsin’s Pandemic Flu Resource.
Beginning July 1, the Wisconsin Department of Health Services will host summits in Appleton, Sauk City, Superior, Milwaukee, and Marshfield to identify and consider the health care community’s interests, requirements, and priorities with respect to Health Information Exchange (HIE). The summits are part of Wisconsin’s HIE initiative, which was formed to help Wisconsin claim its share of $2 billion set aside in the American Recovery and Reinvestment Act for implementing health information technology and exchange across the nation. Health care organizations, associations, and insurers; hospitals; physicians; health care providers; consumers; state and local government representatives; and Tribal Government representatives are encouraged to attend the summits.
You can read more about the Health Information Exchange Initiative and find the schedules for the upcoming summits by reading the DHS’s press release here.
Providers should begin preparing for the Recovery Audit Contractors (RACs). In Wisconsin, the earliest possible dates for automated review will begin this August with DRG validation and coding error review to begin no earlier than October or November 2009. DME medical necessity reviews (complex reviews) will begin in Fiscal year 2010, while medical necessity reviews (complex reviews) are slated to begin in calendar year 2010.
Visit the RAC web site for more information.
On June 23, 2009, IRS TE/GE Commissioner Sarah Hall Ingram gave a speech entitled “Nonprofit Governance – The View From the IRS.” The text of the speech is available at the IRS web site. Ms. Ingram noted that the IRS is concerned with transparency in tax-exempt organizations, especially concerning the use and safeguarding of tax-exempt assets. The IRS has identified important governance topics on its web site and governance questions are embedded in Part VI of the new Form 990. Ms. Ingram also spoke about the IRS’ newly formed Review of Organizations Unit and the Exempt Organizations Compliance Area, which allows the IRS to greatly expand the use of compliance checks.
The Kaiser Family Foundation’s side-by-side interactive comparison tool enables users to compare topics in recent health care reform proposals (i.e. the Senate HELP Committee proposal and the House Tri-Committee proposal). You can access the interactive tool and other documents that provide side-by-side comparisons at the Kaiser Family Foundation’s web site by clicking here.
On June 9, 2009, Senator Edward Kennedy of the Senate Committee on Health, Education, Labor and Pensions released the initial draft of a comprehensive health care reform bill – the American Health Choices Act (the “AHCA”). According to a press release available on Senator Kennedy’s web site, the AHCA includes five major elements:
- Choice: Providing Americans with a choice between the coverage they have now, and new, more affordable options.
- Cost Reduction: Reducing health care costs and minimizing fraud, abuse and unnecessary procedures.
- Prevention: Promoting practices to prevent disease before it arises.
- Health System Modernization: Investing in a workforce for a modern and responsive health care system.
- Long Term Care and Services: Enabling the elderly and disabled to live at home and function independently.
The full text of the AHCA is available here.
On June 19, 2009, a Tri-Committee consisting of the House Committees on Ways and Means, Energy and Commerce, and Education and Labor released its discussion draft of health care reform legislation. The Tri-Committee’s plan addresses health insurance coverage and choice, health insurance affordability, shared responsibility among employees and employers, prevention and wellness, workforce investments and cost control. You can view the Tri-Committee’s summary of the draft legislation here and the full text of the draft here.
The Centers for Medicare and Medicaid Services (“CMS”) recently released new guidance for nursing home surveyors. The new guidance focuses on improving the quality of life and the environment for nursing home residents. The guidance aims, in part, to provide residents with a homelike environment. You can access CMS’s press release here and the guidance for surveyors here.
On June 18, 2009, the Centers for Medicare and Medicaid Services (“CMS”) posted information on its web site warning that perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (“MAC”). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.
Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found at http://www.cms.hhs.gov/MLNGenInfo/ or http://www.cms.hhs.gov/MedicareProviderSupEnroll.
On June 8, 2009, the Office of Inspector General (the “OIG”) of the Department of Health and Human Services (“DHHS”) released its Semiannual Report to Congress (the “Report”). This Report summarizes the OIG’s activities from October 1, 2008 to March 31, 2009. In the Report, the OIG announced significant expected recoveries from audit-related and investigative-related receivables due to its efforts to reduce fraud, waste, and abuse in DHHS’s programs. The Report also summarizes a variety of the OIG’s major accomplishments for the year. Click here to read the full text of the Report.
