Category Archives: Pennsylvania

The UPMC – Highmark Dispute: The Beginning of the End of Medical Practices Using Hospitals’ Managed Care Contract Rates?

Recent trends across the country have health systems buying out private physician practices and reclassifying them as hospital-outpatient departments.  There are a number of motivations behind these transactions, the greatest being managed care contracting.  Typically, the physician practice will reassign its Medicare NPI Number to the Hospital and the Hospital will then bill exclusively under that NPI number.  The Hospital will also submit claims to the third party payor and receive payments based on the hospital’s negotiated contract rates and fee schedule.

Critics, including a number of insurers, have claimed that this practice allows the hospital to bill higher rates for the same service at the same location.  For this reason, on February 26, 2014, Highmark, a  Blue Cross Blue Shield company based in Pittsburgh, stated that it would stop reimbursing health systems at higher hospital-outpatient rates for cancer treatment performed in physician offices.  Highmark explained that this move would save patients’ money by reducing out-of-pocket costs for deductibles and co-insurance. Continue reading

Relator’s FCA Claims Barred By Public Disclosure Bar And For Failing To Be An Original Source

On January 25, 2013, the U.S. District Court for the Eastern District of Pennsylvania dismissed with prejudice the False Claims Act (“FCA”) claims that were alleged by a qui tam relator against two drug manufacturers because the whistleblower’s allegations were substantially similar to those that had been previously publically disclosed and the relater was not an original source of information.  The court then also declined to exercise supplemental jurisdiction over the remaining state law claims.  U.S. ex rel. Schumann v. AstraZeneca Pharmaceuticals LP, No. 03-5423, 2013 WL 300745 (E.D. Penn. Jan. 25, 2013).  The same court previously dismissed identical FCS claims against Bristol-Meyers Squbb Company in an earlier opinion.  U.S. ex rel. Schumann v. AstraZeneca PLC, No. 03-5423, 2010 WL 4025904 (E.D. Penn. Oct. 13, 2010). Continue reading