Healthcare Reform

Tracking Legislative & Regulatory Change

From Congressional budget deals that tweak Medicare conversion factors to state bills redefining scope of practice, our healthcare reform posts explain how evolving statutes may influence medical decision-making, office work-flows, and payer negotiations. We connect the dots between headline votes and real-world clinic operations, spotlighting key provisions on payment models, telehealth flexibility, prior authorization, and interstate licensure compacts.

Analyzing Agency Rules & Guidance

The Centers for Medicare & Medicaid Services, the FTC, and state boards frequently publish rulemakings that affect reimbursement and compliance. Our articles summarize the practical pieces—effective dates, required disclosures, documentation standards—so physicians can adjust coding processes, update consent language, or join new alternative payment programs with minimal disruption.

Physician Autonomy & Practice Economics

Healthcare reform debates often pivot on consolidation, ownership restrictions, and value-based care incentives. We discuss how policies such as site-neutral payment proposals, surprise-billing regulations, and antitrust enforcement may influence the viability of independent practices versus hospital employment. Posts highlight contract clauses to watch, pitfalls in acquiring ancillary services, and strategies for sustaining revenue as payment structures evolve.

Practical Tips Rooted in Real Cases

Every commentary includes actionable insights—sample language for payer appeals when codes are retired, talking points for patient cost-of-care conversations after a benefit redesign, and checklists for updating compliance manuals. We draw on Dr. Jeffrey Segal’s dual perspective as surgeon and attorney to illustrate how one practice modified its financial policy after a change in balance-billing rules, or how another leveraged state innovation waivers to expand telehealth reach.

Key Topics We Discuss

• MACRA and QPP updates
• Interoperability & information-blocking rules
• Scope-of-practice expansion bills
• Federal price-transparency mandates
• State efforts to curb prior authorization delays

The 81 Million Dollar Misdemeanor

August 15, 2024April 29, 2010 by Jeffrey Segal, MD, JD

Breaking news today: “Two pharmaceutical subsidiaries of Johnson & Johnson will pay more than $81 million and plead guilty to a misdemeanor charge in a U.S. Justice Department case about illegal promotion of the epilepsy drug Topamax, federal officials announced.”

Let’s reread that one, break it down and let it sink in. The U.S. Justice Department has one misdemeanor case against Ortho-McNeil Neurologics and Noramco. The complaint is illegal promotion of a drug most people haven’t ever heard of. The promoting of a drug which has already been released as generic should cost Johnson & Johnson (the manufacturer’s parent company) 81 MILLION dollars in fines?

This isn’t a drug that has caused deaths. It’s not even inherently responsible for injuries. The drug isn’t the issue. The means of promoting it is. And that earns the Feds 81 MILLION dollars?

Senate Positioning to Regulate Health Insurance Premiums

August 15, 2024April 28, 2010 by Jeffrey Segal, MD, JD

Senator Dianne Feinstein (D, CA) staked claim on controlling potential unwarranted insurance rate hikes by explaining her position: “Water and power are essential for life, so they are heavily regulated, and rate increases must be approved.” Likewise, she states, “Health insurance is also vital for life. It too should be strictly regulated so that people can afford this basic need.” Some may think the claim is mostly sophistry, but the Senator has a valid point. As it stands now, there’s a gaping loop hole for insurance companies. They may be required to accept pre-existing conditions, for example, but there’s currently nothing to stop them from gouging the rates into stratospheric proportions. A major concern about the HCR bill has always been that the insurance companies would pass the rate increases — increases that would make the cost of premiums so high that even the most affluent of the middle class would struggle to afford health insurance.

Hard Time Getting A Doctor’s Appointment? Thank a Greedy Lawyer.

August 15, 2024April 23, 2010 by Jeffrey Segal, MD, JD

Everyone knows times are tough these days, but there’s a big difference between hanging out your shingle far enough for it to be seen and active selling. And that difference is driving good, caring, competent physicians out of practice in droves. Between the tough economic times overall, the chronic changes in government reimbursement, the hassle and delay in collecting at all, and the way that insurance companies come back and renegotiate after services have been provided… it’s no surprise that people have a hard time getting in to see the doctors that are still in practice.

They say it pays to advertise. Apparently it pays very well for jackpot trial attorneys. Medical Malpractice attorney’s commercials are all over daytime and late-night TV… now on the Internet as well.

Do You Feel You’ve Suffered From Your Doctor’s Neglect? Contact A Malpractice Attorney Now!

We’ve removed the links (why advertise for the enemy?) but the text remains the same.

The Liz Fowler Connection: WellPoint Commits Fraud, Targets Patients For Wrongful Cancellation

August 15, 2024April 22, 2010 by Jeffrey Segal, MD, JD

Federal investigators have revealed that the largest health insurance company in the country, WellPoint, is using a computer program to identify women with breast cancer. Why? To drop their coverage. Murray Waas, a well-respected investigational journalist, states WellPoint “specifically targeted women with breast cancer for aggressive investigation with the intent to cancel their policies.” Last month, Waas reported that AIDS patients were being similarly targeted for rescission. That practice has been going on since at least 2002, as is well-evidenced by the unlawful cancellation and subsequent cover-up in the Jerome Mitchell case.

Doctor: You Promised My Before and After Website Pictures Would be Anonymous

August 15, 2024April 22, 2010 by Jeffrey Segal, MD, JD

Many aesthetic surgeons place before and after pictures on their websites. Obtain patient’s detailed written permission before moving forward. Check. Place a black strip over identifying features if not highlighting facial features. Check. That’s it. Right? RIGHT?? Wrong. One surgeon learned that a de-identified photo had the patient’s name embedded in file name / properties … Read more

Health Care Reform Bill: Now Comes The Hard Part

August 15, 2024April 21, 2010 by Jeffrey Segal, MD, JD

It took Congress over a year to compile and construct it. It took creative maneuvers to pass it into law. Already unfounded fears are sticking doctors in the middle of what it means to their patients. Now comes the hard part. The Obama Administration now has to turn 2400 pages of words into changes in Health Care. Here’s the latest on the teams that are supposed to do it:

Jay Angoff, consumer advocate, known nemesis of the insurance industry, heads up implementation of the regulation of insurers and insurance markets.
Jeanne M. Lambrew comes back with experience from the Clinton administration to work on expanding coverage.
Phyllis C. Borzi, a top Labor Department official, is assigned to ensure that employers are following the rules for some 150 million American insured persons.

Doctors Already Besieged by Questions About the new Health Care Laws

August 15, 2024April 19, 2010 by Jeffrey Segal, MD, JD

Though they wouldn’t have time to read the 2400 pages that are in it, though they had no real say in its contents and may even have been opposed to it, physicians all over the country are finding themselves bogged down by questions about the new health care reform law. Like most people, their patients are afraid of change. Some want to know if they will still be able to see their doctor. Others want to schedule surgeries before they even need them, out of fear that they may not be covered later. All of these questions are reasonable concerns, considering the relative vacuum of information on the practical implications and implementations of the new law. Nevertheless, they’re already starting to bog down some practices.

Medicare Cuts Postponed Again — this time until June 2010

August 15, 2024April 16, 2010 by Jeffrey Segal, MD, JD

One can easily wonder why they don’t just approve full payments for a year or two at a time. They can always eliminate it by future legislation once they determine what formula they DO want to use.

AHA Calls for Easing of New Rules on Electronic Health Record Requirements

August 15, 2024April 15, 2010 by Jeffrey Segal, MD, JD

…the ad states that the CMS’ proposed rule “proposes strict requirements that constrain hospitals as they work to implement new EHR systems, imposing a one-size-fits-all policy that ignores upfront cost, time and logistical challenges.”

Georgia First State to Rebel Against High Risk Pool in Healthcare Reform

August 15, 2024April 14, 2010 by Jeffrey Segal, MD, JD

The official version is that it’s a budgetary issue – that seems unlikely. John Oxendine, Georgia’s insurance commissioner, a Republican, has his eye on the Governor’s mansion in the upcoming election. The rebellion is cleverly wrung; no patients will lose any benefits nor will it affect the cost of insurance for Georgians. What it does is make a statement; while putting the burden on the Federal government to oversee the distribution of funds to those in need within the state.

Further proof of the real cause of the insubordination is found in Oxendine’s letter to Kathleen Sebelius, U.S. Secretary of Health & Human Services. In that letter, he said that he would not involve Georgia in “a scheme which I believe the Supreme Court will hold to be unconstitutional, leads to the further expansion of the federal government, undermines the financial security of our nation, and potentially commits the State of Georgia to future financial obligations.” Obviously it wasn’t really about the state’s cost of administering the funds provided by the Federal government. Using the fate of uninsured high-risk citizens as a soapbox for a political statement is transparent. The Republican Primary for Governor is coming up in July. Oxendine hopes to distinguish himself from the field with this move, even though the action changes nothing – amounting to nothing more than token blustering.

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