Health Care

Subscribe to Health Care via RSS

In this crossover episode of Payments Pros and The Consumer Finance Podcast, guest host Taylor Gess dives into the rapidly evolving world of point-of-sale financing for medical and dental procedures with Troutman Pepper Locke Partners Jason Cover, Brent Hoard, and Erin Whaley. They unpack how HIPAA, business associate relationships, and information-sharing structures can impact financing programs in clinical settings. They explore state-level trends in California, Illinois, and New York, including new restrictions on provider involvement in financing, promotional offers, and payments. The discussion also highlights emerging risks around website tracking technologies, payment portals, and wiretapping-style lawsuits targeting digital health and payment ecosystems. Listeners will come away with a practical framework for structuring medical and dental financing arrangements, managing disputes, and anticipating the next wave of state-level regulation and enforcement.

In this crossover episode of The Consumer Finance Podcast and Payments Pros, guest host Taylor Gess dives into the rapidly evolving world of point-of-sale financing for medical and dental procedures with Troutman Pepper Locke Partners Jason Cover, Brent Hoard, and Erin Whaley. They unpack how HIPAA, business associate relationships, and information-sharing structures can impact financing programs in clinical settings. They explore state-level trends in California, Illinois, and New York, including new restrictions on provider involvement in financing, promotional offers, and payments. The discussion also highlights emerging risks around website tracking technologies, payment portals, and wiretapping-style lawsuits targeting digital health and payment ecosystems. Listeners will come away with a practical framework for structuring medical and dental financing arrangements, managing disputes, and anticipating the next wave of state-level regulation and enforcement.

On January 7, the U.S. Court of Appeals for the First Circuit denied the federal government’s request for a stay of the nationwide preliminary injunction barring implementation of the Health Resources and Services Administration’s (HRSA) 340B Rebate Model Pilot Program. Five days later, on January 12, the Department of Justice advised the court that the parties are discussing returning the challenged approvals to HRSA for reconsideration and that they “plan to dismiss the appeal in short order,” signaling that the current version of the pilot is unlikely to move forward on appeal.

On January 12, the U.S. Supreme Court denied the petition for writ of certiorari in Guardian Flight, leaving in place the Fifth Circuit’s June 2025 decision that we covered in our prior post (available here). As a result, within the Fifth Circuit, providers cannot rely on the No Surprises Act (NSA) itself to enforce Independent Dispute Resolution (IDR) awards in court and face a heightened standing bar for ERISA-based claims where patients are insulated from financial harm. And the persuasive effect of the Fifth Circuit’s holding is bolstered nationwide.

On December 29, 2025, Chief Judge Lance Walker of the U.S. District Court for the District of Maine granted the plaintiffs’ motion for a preliminary injunction in American Hospital Association v. Kennedy. The court enjoined implementation of HRSA’s 340B Rebate Model Pilot Program “pending further order,” blocking the program from going into effect on January 1, 2026 (and April 1, 2026 for one manufacturer).

Colorado House Bill 25-1002, effective January 1, 2026, amends Colorado Revised Statutes § 10-16-104(5.5) to require health benefit plans to use nationally recognized, not-for-profit clinical criteria when making coverage and utilization review determinations for behavioral health, mental health, and substance use disorder treatment. The statute establishes a uniform approach to coverage and utilization review and tightens state-level expectations for compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA).

A coalition of hospital associations and individual safety‑net providers recently filed suit in the U.S. District Court for the District of Maine challenging the Health Resources and Services Administration’s (HRSA) newly announced 340B Rebate Model Pilot Program, alleging violations of the Administrative Procedure Act (APA). As framed in the complaint, the program would replace the 30‑year‑old practice of offering 340B discounts at the point of sale with a post‑dispense rebate for a set of high‑volume drugs, compelling covered entities to pay wholesale acquisition cost (WAC) upfront and then pursue reimbursement from manufacturers. The plaintiffs contend the shift will impose hundreds of millions of dollars in administrative and cash‑flow costs on safety‑net hospitals, jeopardize care in rural and underserved communities, and reflect a sudden, unexplained reversal of HRSA’s longstanding position that upfront discounts are the most effective and efficient way to administer the program.

Private equity’s footprint in health care has expanded rapidly over the past decade, and in response states have begun to retool long‑standing doctrines and create new guardrails that target ownership, control, and transparency. The result is an emerging patchwork of laws and review processes that remake the corporate practice of medicine landscape, constrain common “friendly PC” structures, and require far more visibility into transactions involving private equity, hedge funds, real estate investment trusts (REITs), and management services organizations (MSOs).

On November 24, the Ninth Circuit issued an unpublished memorandum disposition in Dedicato Treatment Center, Inc. v. Aetna Life Insurance Co., affirming dismissal of an out-of-network provider’s state-law claims as preempted by ERISA’s remedial scheme. The panel’s brief decision underscores that the Court’s 2024 decision in Bristol Holdings (discussed here) applies broadly to state-law causes of action arising from pre-service verification-of-benefits and authorization communications, even where a provider also pleads an alternative ERISA benefits claim pursuant to an assignment of benefits from the member. Although not precedential under Ninth Circuit Rule 36-3, the disposition is a clear, persuasive affirmation of Bristol’s reach.

On October 31, CMS finalized the CY 2026 Medicare Physician Fee Schedule (PFS) rule (CMS-1832-F), effective January 1, 2026. While primarily directed at Medicare providers, the rule’s changes have clear downstream effects for payors and private insurers that benchmark to Medicare or align commercial policies with federal payment logic. Key themes are higher baseline rates, a stronger push toward value-based care via dual conversion factors, permanent telehealth flexibilities (including virtual supervision), expanded behavioral health integration, and a cost-containment overhaul for skin substitutes.