United Healthcare Oxford Medicare Advantage Denies Coverage

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Medicare (Health and Medical Issues Today)

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False Advertising Claim Over Statements In Billing Letter To Patients Not Sufficiently Pled Under Lanham Act

The Court found Ameritox’s factual allegations that the letter was misleading to be sufficient, but at the same time Ameritox had not plausibly pled that the billing letter was likely to deceive potential customers.  The Court did not explain these seemingly contradictory findings beyond stating that Ameritox’s allegation that “Millennium’s statements are…likely to deceive a substantial portion of the targeted customers,” was nothing more than a naked assertion devoid of further factual enhancement – the type of pleading prohibited by the Supreme Court’s decisions in Iqbal and Tombly.  It is not clear what factual enhancement the Court would accept as sufficient to support an allegation of likelihood of deception.  Professor Tushnet wonders whether Ameritox may have to plead that it has a survey in hand. See http://tushnet.blogspot.com/2012/01/pleading-standard-dooms-misleadingness.html.  It seems to this author that explaining how an advertisement is misleading usually would be sufficient to underpin how it is likely to deceive potential consumers.  For example, here (assuming what Ameritox states turns out to be true, as one must on a motion to dismiss), it seems that Ameritox is claiming that patient-consumers are likely to be deceived into believing they are receiving a benefit by having their tests conducted by Millennium because of Millennium’s statements about patients not having to make co-pays, etc.  Perhaps Ameritox needs to be explicit on this point when it amends its complaint, even if such pleading seems above and beyond the notice pleading required by the Federal Rules.
Source: pattishall.com

“Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy” ed. by Margaret Edmunds and Frank A. Sloan

This report assesses existing practices in regards to accuracy, criteria consistency, evidence for adjustment, sound rationale, transparency, and separate policy adjustments to reform the current payment system. Adopting the recommendations outlined in this report will mean a change in the way that the indexes are calculated, and will require a combination of legislative, rule-making, and administrative actions, as well as a period of public comment.Medicare is the largest health insurer in the United States, providing coverage for 39 million people aged 65 and older and 8 million people with disabilities, and reaching more than an estimated $500 billion in payments in 2010.ContentsACRONYMS GLOSSARYSUMMARY 1 INTRODUCTION AND OVERVIEWGoal of This StudyGeographic Adjustments to Medicare PaymentHospital Wage Index Geographic Practice Cost Indexes Budget Neutrality and Provider Impact Payment Equity Concerns and Rationale for This Study Principles and Assumptions Research Framework for the Study References 2 LABOR MARKETS AND PAYMENT AREAS Factors of Production The Market for Labor How and Why Do Health Care Wages Differ Geographically? Defining Markets Existing Payment AreasCommittee Assessment of Existing Payment Areas Alternative Labor Market Options Considered by the Committee Committee Recommendations References 3 THE HOSPITAL WAGE INDEX Details of the Hospital Wage Index Committee Assessment of Wage Index Alternatives Hospital Wage Index and Other FacilitiesOther Issues Committee Recommendations References 4 SMOOTHING THE BORDERS OF LABOR MARKETS AND PAYMENT AREASAdjustment Approaches Under Current Hospital Wage IndexAdjustment Approaches Considered by the Committee Committee Recommendations References 5 GEOGRAPHIC PRACTICE COST INDEXES Geographic Adjustments to Fee-For-Service Payments Geographic Adjustment Factor Components Work GPCI Practice Expense (PE GPCI) Professional Liability Insurance Committee Recommendations References 6 TRANSITIONS What This Study Sought To Do Challenges and Limitations of the Study Areas of Focus for the Committee’s Final Report Considerations for the FutureReferences APPENDIXESA Committee and Staff Biographies B Public Committee Meeting Agendas C List of Contributors and Participants D Statistical Reliability of the BLS Wage Data E Comparison of the MedPAC and IOM Proposals for Alternative HWIs F Description of Three Optional Sources for Facility Wage Index Data G RTI Analysis Data Sources H S-3 Worksheet I Physician Work Adjustment
Source: e-bookstube.com

United Healthcare Oxford Medicare Advantage Denies Coverage

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