Holland & Hart Healthcare Law Blog

Wisconsin Supreme Court Orders HMO to

In Summers v. Touchpoint Healthplan, Inc., Case Number 2005-AP 2643 (Wisc. May 28, 2008), the Wisconsin Supreme Court ordered Touchpoint to provide coverage for an "experimental" high dose radiation and stem cell recovery procedure for a child suffering from a rare brain tumor. Surgeons removed the tumor and the child’s doctors recommended the high dose radiation treatment with stem cell recovery as the best of the follow-up options to assure full recovery. The problem was that the procedure was "experimental" as defined in the policy and was excluded from coverage under the policy. Included in the plan’s definition of "experimental" was any procedure that was the "subject of any ongoing Phase I or Phase II clinical trial."

Wisconsin Supreme Court Orders HMO to

In Summers v. Touchpoint Healthplan, Inc., Case Number 2005-AP 2643 (Wisc. May 28, 2008), the Wisconsin Supreme Court ordered Touchpoint to provide coverage for an "experimental" high dose radiation and stem cell recovery procedure for a child suffering from a rare brain tumor. Surgeons removed the tumor and the child’s doctors recommended the high dose radiation treatment with stem cell recovery as the best of the follow-up options to assure full recovery. The problem was that the procedure was "experimental" as defined in the policy and was excluded from coverage under the policy. Included in the plan’s definition of "experimental" was any procedure that was the "subject of any ongoing Phase I or Phase II clinical trial."

OIG BLESSES DENTAL PPO PAYMENT TO MARKETING FIRM FOR SIGNING UP FEDERAL EMPLOYEES HEALTH PLAN

Did it ever occur to you that a Preferred Provider Organization might run afoul of the federal anti-kickback statute by paying for the services of a marketing firm on the basis of PMPM (per member per month)?  On October 13, 2006 the OIG posted advisory opinion No. 06 17.  The dental network (the “Network”) contracted with a marketing firm for services.  The marketing firm introduced a third party administrator (“TPA”) to the network.  The marketing TPA made the network available to one of its clients, a Federal employee health benefits plan.  Most of the beneficiaries in the Federal employee health benefit plan do not qualify for federal healthcare benefits programs, although some do.

Colorado Managed Care Review 2003 finds HMO Profits Rise As Enrollment Drops.

(Denver) After reporting net income of more than $100 million in 2002, Colorado HMOs have already posted $93 million in profits in the first half of 2003. These profits were fueled by four straight years of double-digit premium increases. However, enrollment has dropped sharply for the third straight year. Hospital net income has increased and four new hospitals are opening in the next year.

Supreme Court To Hear Conflicting HMO ERISA Cases Involving Patient Access To Care.

The United States Supreme Court agreed today to hear two conflicting patient rights cases involving ERISA preemption of State Law where an HMO refuses to provide coverage or provides treatment different than that recommended by the patient's physician. The 1974 ERISA statute passed Congress long before the wide spread penetration of managed care in our health care system. The cases, Aetna Health Inc. v. Davila, 02-1845 and Cigna Healthcare of Texas Inc v. Caldad, 03-83, deal with the sticky question of whether a patient's sole recourse is to federal courts and limited to recovery of the service denied under ERISA.