Many Medicare Advantage Organizations (“MAOs”) are not contracted with providers. When an MAO enrollee presents to the provider for healthcare services, the provider verifies the enrollee’s coverage, obtains authorization where necessary, and renders the requisite services. The provider then submits a claim to the MAO for payment, and the MAO adjudicates payment. Nevertheless, in many
In a unanimous decision issued on May 23, 2022, the U.S. Supreme Court reversed a long-standing requirement in several circuits that parties opposing arbitration demonstrate prejudicial harm before an arbitration clause is considered waived. Morgan v. Sundance, Inc. involved an employment dispute in which the employer engaged in litigation for eight months before seeking to compel arbitration
On April 12, 2022, the Centers for Medicare & Medicaid Services (“CMS”) issued new guidance regarding the federal Independent Dispute Resolution (IDR) process, created under the No Surprises Act (NSA) to provide a mechanism for payers and providers to resolve disputes pertaining to the appropriate reimbursement amount for certain qualifying out-of-network claims.