Providers can look to HHS fraud model; the Office of Inspector General's antifraud model for labor can help all providers ward off claims of Medicare and Medicaid fraud

Article Abstract:

Medical providers can look to the model compliance program put out by the Office of the Inspector General of the Department of Health and Human Services. Although issued for medical laboratories that must test Medicare and Medicaid beneficiaries and intended to uncover improper billing and fraud in such programs, the model has elements helpful to all medical providers. Medical providers with corporate compliance programs decrease the chance of a whistleblower suit and can decrease criminal penalties under the federal guidelines for sentencing organizations if convicted of a billing-related crime. Providers can even use such programs to distinguish themselves from competitors in marketing efforts. Elements of the model plan are listed.

Models, Laws, regulations and rules, Health services administration, United States. Department of Health and Human Services. Office of Inspector General

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ERISA pre-empts many HMO claims; but courts are split on whether HMOs can be vicariously liable in state-law malpractice suits

Article Abstract:

ERISA pre-emption limits the remedies available in medical malpractice suits against health maintenance organizations (HMOs), so pre-emption principles are key to health care litigation and regulations. The courts have defined ERISA pre-emption broadly. In vicarious liability actions the key to pre-emption is whether the HMO's performance of that of a related doctor is at issue. Allegations in the complaint often provide the definition. The possibility of pre-emption should always be considered in view of ERISA's remedy limitations. ERISA has a potential impact on all suits involving managed care medicine.

Medical personnel, Malpractice, Medical malpractice, Respondeat superior, states

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7th Circuit: HMO isn't a monopoly; as a recent Wisconsin case shows, defining a relevant market for health care antitrust purposes has become increasingly difficult

Article Abstract:

The 7th Circuit recently overturned an antitrust verdict against Marshfield Clinic in WI, making it harder to prove monopolistic practices and define a market. Blue Cross & Blue Shield United of WI, together with HMO subsidiary Compcare, claim Marshfield and its subsidiary HMO control the north central WI region, that they charge above market rates, and that they conspired to allocate markets horizontally. Chief Judge Richard Posner of the 7th Circuit decided HMOs form no relevant market and upheld only the last claim.

Antitrust law, Unfair competition (Commerce), Unfair competition

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