United States: CMS Releases The 2019 MPFS And QPP Final Rules

Miranda A Franco is Senior Policy Advisor in Holland & Knight's Washington D.C. office

HIGHLIGHTS:

  • The Centers for Medicare & Medicaid Services (CMS) has published the Calendar Year (CY) 2019 Final Rule for the Medicare Physician Fee Schedule (PFS), which includes provisions related to Medicare physician payments as well as regulations for the Quality Payment Program (QPP).
  • Among notable changes, CMS finalized policies that would reduce provider reimbursement rates for new drugs under Medicare Part B, increase access to telehealth services, and revise a controversial evaluation and management proposal.

The Centers for Medicare & Medicaid Services (CMS) on Nov. 1, 2018, published the Calendar Year (CY) 2019 Final Rule for the Medicare Physician Fee Schedule (PFS). Although in previous years regulations for the Quality Payment Program (QPP) were released independently, the 2019 Medicare PFS Final Rule includes provisions related to Medicare physician payments as well as the QPP. The MPFS dictates Medicare rates and policies under Part B, while the QPP implements two key value-based payment programs: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Most of the provisions of the Final Rule take effect on Jan. 1, 2019; however, CMS pushed the start date until CY 2021 for certain burden reduction proposals in response to concerns from stakeholders.

CMS noted throughout the Final Rule that it wanted to continue to provide physicians and other healthcare practitioners relief from excessive regulation and to reduce compliance needs that interfered with patient care. However, with the QPP, International Pricing Index Model and other demonstrations, that remains to be seen.

Among notable changes, CMS finalized a policy that would reduce provider reimbursement rates for new drugs under Medicare Part B by 3 percent during the first quarter of sales when the average sales price (ASP) is unavailable. The Trump Administration first floated the change in its fiscal 2019 budget proposal released in February 2018, and the idea previously had been recommended by the Medicare Payment Advisory Committee (MedPAC)in its June 2017 Report to the Congress. CMS did not provide an estimate of how much the new policy would be expected to reduce Medicare expenditures.

The Final Rule also includes increased access to telehealth services. Specifically, CMS finalized distinguishing between Medicare telehealth services and "communication technology-based and remote evaluation services." This distinction would permit Medicare reimbursement for services that do not meet the statutory requirements for Medicare-reimbursable telehealth services. Ultimately, CMS finalized paying clinicians for virtual check-ins and for evaluations made from patient-submitted photos/images ("store and forward applications.") With CMS clearly warming to telehealth, Congress may not be too far behind.

Additionally, CMS scaled back and delayed for two years proposed changes to overhaul Medicare billing practices that have been in place for routine office visits since 1995.Instead of finalizing the blended rates for evaluation and management (E/M) codes for CY 2019 and 2020, CMS is implementing changes to the documentation policy but maintaining the current payment structure. However, starting in CY 2021 and beyond, CMS will change the payment structure by paying a single rate for E/M office visit Levels 2 through 4 for established and new patients, while maintaining the payment rate for E/M office visit Level 5.

Visit the CMS website for its MPFS Fact Sheet and QPP Fact Sheet.

Final Rule Highlights

Medicare Physician Fee Schedule (PFS) Updates

General Payment and Relative Value Unit (RVU) Updates: The finalized 2019 MPFS conversion factor is $36.046, a slight increase above the 2018 MPFS conversion factor of $35.9996. CMS added practice experience (PE) utilization data for two new specialties: 1) Hospitalists and 2) Advanced Heart Failure and Transplant Cardiology.

Update to Wholesale Acquisition Cost (WAC)-Based Payment for Part B Drugs: While most Part B drugs are paid at Average Sales Price (ASP) plus 6 percent of ASP, certain drugs are currently paid at WAC plus 6 percent until more data is available (generally by the third quarter). CMS finalized a proposal to reduce these payments to WAC plus 3 percent and allow Medicare Administrative Contractors the authority to pay at WAC plus 3 percent as well. CMS notes that this policy is consistent with recent recommendations from MedPAC.

Evaluation and Management (E/M) Visits: Instead of finalizing the blended rates for E/M codes for CY 2019 and 2020, CMS is implementing changes to the documentation policy but maintaining the current payment structure,affording stakeholders additional time to engage with the agency. For CY 2019 and beyond, CMS finalized the below policies.

  • It eliminated the requirement to document the medical necessity of a home visit in lieu of an office visit.
  • For office/outpatient visits for established patients, when relevant information is already contained in the medical record, physicians can focus their documentation on what has changed since the last visit, or on pertinent items that have not changed.
  • For E/M office visits for new and established patients, physicians can indicate they reviewed and verified the information, so they do not need to re-enter in the medical record information on the patient's chief complaint and history that has already been entered by ancillary staff or the beneficiary.
  • CMS removed potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Starting in CY 2021 and beyond, CMS will make the following changes to the payment structure.

  • CMS will collapse code Levels 2 through 4 into one level and will pay providers a single rate (one each for established and new patients), but it will maintain the Level 5 code, which accounts for care provided to the most complex patients. CMS had originally proposed folding the Level 5 code into the single rate.
  • CMS estimates that, once the new payment policies are implemented in 2021, it will disproportionally benefit specialties that report lower-level visits, such as podiatry (+10 percent), as well as specialties that report E/M visits in conjunction with minor procedures, such as dermatology (+4 percent).
  • The change in the proposal to maintain a Level 5 visit for highly complex patients mitigates the estimated impacts on specialties that report many highly complex visits, such as allergy/immunology (was -5 percent, now 0 percent), hematology/oncology (was -4 percent, now 0 percent) and rheumatology (was -4 percent, now -1 percent).
  • Physicians will also have the option to receive higher rates with the creation of a new "extended visit" code to account for additional time spent with patients whose visits are coded at Levels 2 through 4.
  • The agency also said, beginning CY 2021, it will allow clinicians to rely more on their own medical decision-making or the time spent with a patient to determine the level of a patient's care needs.

Further, in response to comments from external stakeholders, CMS will not finalize the following proposals:

  • reduced payment for E/M services that are furnished on the same day as procedures
  • separate coding and payment for podiatric E/M visits
  • standardized allocation of practice expense relative value units (RVUs) for the codes that describe these services

Telehealth Updates: CMS finalized a policy to add separate Medicare reimbursement for two types of services:

  1. Brief Communication Technology-Based Service (HCPCS Code: G2012), e.g., Virtual Check-In. Virtual check-ins are "brief check-in services furnished using communication technology that is used to evaluate whether or not an office visit or other service is warranted." Under CMS' regulation, virtual check-ins would be eligible for separate payment, but these services would not be billable if they originated from or led to another, related E/M service by the same physician or qualified health care professional within the previous seven days, or led to an E/M service or procedure within the next 24 hours or soonest available appointment.
  2. Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (HCPCS Code: G2010). Like virtual check-ins, these "store and forward" services would not be billable if they originated from or led to another, related E/M service by the physician or qualified health care professional within the previous seven days, or led to an E/M service or procedure within the next 24 hours or soonest available appointment. G2010 may be billed only for established patients. CMS finalized that the follow-up with the patient could take place via phone call, audio/video communication, secure text messaging, email or patient portal communication. CMS also finalized that beneficiary consent may be verbal or written, including electronic confirmation that is noted in the medical record for each billed service for HCPCS code G2010.

The communication technology-based and remote evaluation services do not satisfy the requirements for Medicare telehealth services as set forth in Section 1834(m) of the Social Security Act, 42 U.S.C. §1395m(m), but in the Final Rule, CMS takes the view that the Medicare telehealth standards do not apply to services that "inherently involve the use of communication technology."

CMS also finalized adding prolonged preventive services (HCPCS Codes G0513 and G0514) to the list of Medicare telehealth services that can be reimbursed when provided via telehealth and in compliance with CMS' reimbursement requirements for telehealth services, including originating site restrictions and geographic requirements.

CMS also finalized policies to pay separately for new codes describing chronic care remote physiologic monitoring (CPT codes 99453, 99454 and 99457) and interprofessional internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448 and 99449).

In addition, beginning July 1, 2019, CMS will increase access to telehealth services for opioid use disorder treatment by removing the originating site geographic requirements and allowing providers to be reimbursed for telehealth services originating in an individual's home for the treatment of a substance use disorder or a co-occurring mental health disorder.

Off-Campus Provider-Based Hospital Department Payments (Section 603): For non-excepted departments paid under the MPFS, CMS maintained its CY 2018 payment Relativity Adjuster of 40 percent of the amount that would have been paid under the Hospital Outpatient Prospective Payment System. This is a decrease from the 50 percent rate in CY 2017.CMS states that this methodology will continue to be standard practice until an alternative payment method is proposed and finalized through rulemaking.

Imaging Appropriate Use Criteria (AUC) Program: Implementation of AUC is set to begin in 2020, with reimbursement penalties for imaging starting in 2021.

CMS finalized its proposed revision to the significant hardship criteria to include criteria related to internet access, vendor issues, and extreme or uncontrollable circumstances. In addition, CMS added independent diagnostic testing facilities (IDTFs) to the definition of applicable settings, allowing the AUC program to be more consistently applied to outpatient settings. CMS also finalized that only auxiliary staff "working under the direction of the ordering professional" can consult CDS.

CMS also clarified that exceptions granted for an individual with an emergency medical condition includes instances where an emergency medical condition is suspected but not yet confirmed. CMS noted this might include, for example, instances of severe pain or severe allergic reactions. In these instances, the exception is applicable even if it is determined later that the patient did not, in fact, have an emergency medical condition.

Clinical Laboratory Fee Schedule (CLFS): CMS finalized its proposal to change the definition of "applicable laboratories" that must report data for the purposes of weighted median payment calculations as implemented following the Protecting Access to Medicare Act (PAMA). The change would modify the definition of an applicable laboratory to exclude Medicare Advantage (MA) plan payments from total Medicare revenues, the denominator of the majority of Medicare revenues threshold.

Changes to Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) Quality Measure Set: The Final Rule included several changes to the MSSP program beyond those included in a separate rule proposed in August. To reduce reporting burden and align MSSP with the Merit-Based Incentive Payments System (MIPS), CMS finalized removal of 10 quality measures and added two quality measures for the payment year (PY) 2019 MSSP quality measure set. The rule also allows beneficiaries who voluntarily align with a nurse practitioner, physician assistant, certified nurse specialist or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO. The Final Rule also revises the definition of primary care services used in the beneficary assignment.

Six-Month Extension to Subset of MSSP ACOs: To address time-sensitive proposals to the MSSP timeline as described in the MSSP ACO Pathway to Success proposed rule, CMS finalized its proposal to grant ACOs whose participation ends Dec. 31, 2018, a six-month voluntary extension from Jan 1, 2019, to June 30, 2019.

Request for Information on Price Transparency: In the Proposed Rule,CMS requested information on price transparency. Although the Proposed Rule did not set forth any specific proposals, CMS stated that it was considering potential actions to promote provider-side efforts "to engage in consumer-friendly communication of their charges" so that patients understand their potential financial liability for services and can compare charges between providers. The agency sought information regarding barriers preventing providers and suppliers from informing patients of their out-of-pocket costs; what changes are needed to support greater transparency around patient obligations for their out-of-pocket costs; what can be done to better inform patients of these obligations; and what role providers of healthcare services and suppliers should play in this initiative. This request for information was also included in the FY 2019 Inpatient Prospective Payment System (IPPS) Proposed Rule.

In the Final Rule, CMS noted that it received 94 responses and will continue to consider the issue. CMS has separately proposed price transparency requirements for direct-to-consumer advertising.

Signature Requirements in Certain Compensation Arrangement Exceptions to the Physician Self-Referral Law: CMS finalized refining the self-referral (Stark) regulations to tighten and clarify the existing law with respect to what qualifies as a written agreement and when a signature must be secured. Specifically, it added regulatory provisions specifying that 1) the writing requirement contained in various compensation arrangement exceptions can be satisfied by "a collection of documents, including contemporaneous documents evidencing the course of conduct between the parties" and 2) the signature requirement can be satisfied if the compensation arrangement meets all of the other requirements of the exception and if the required signatures are obtained within "90 consecutive calendar days immediately following the date" a signature was required but not yet secured. Lastly, CMS includes the final annual update of the list of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) codes that are included in the scope of designated health services to which the Physician Self-Referral Law applies.

Quality Payment Program (QPP) Updates

This year's QPP Final Rule continues to slightly ramp up the Merit-Based Incentive Payment System (MIPS) for eligible clinicians, with CMS increasing the number of clinicians included in MIPS, increasing the threshold score for avoiding a MIPS penalty and increasing the weight of the MIPS cost component.

Advanced Alternative Payment Models (APMs) track policies remained fairly status quo, with some slight policy changes intended to streamline the program and reduce burden for participants.

MIPS Flexibility and Changes: CMS advances minimal changes to the existing MIPS program, affecting the cost, quality and interoperability components.

CMS finalized reweighting the MIPS categories to 45 percent Quality, 25 percent Promoting Interoperability, 15 percent Cost, and 15 percent Improvement Activities.

  • For Quality, CMS finalized the removal of 26 measures (of 34 proposed) from the MIPS program in alignment with the "Meaningful Measures" initiative by removing process-based quality measures that are low-value or low-priority.
  • For Cost, CMS finalized eight episode-based treatment groups into the calculation of the cost category addressing acute and procedural episodes. Currently, the cost category is based on two measures: Total Per Capita Cost and Medicare Spending Per Beneficiary. The eight recently developed, episode-based cost measures include: Elective Outpatient Percutaneous Coronary Intervention (PCI), Knee Arthroplasty, Revascularization for Lower Extremity Chronic Critical Limb Ischemia, Routine Cataract Removal with Intraocular Lens (IOL) Implantation, Screening/Surveillance Colonoscopy, Intracranial Hemorrhage or Cerebral Infarction, Simple Pneumonia with Hospitalization, and ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI). Eligible clinicians may have concerns about an increase in the weight of the cost category to 15 percent in the same year that new episode-based measures may be in effect.
  • For Improvement Activities, CMS removed one previously existing improvement activity, added six new improvement activities (addressing eye exams, navigation, care management, communication, education and patient safety), and modified five improvement activities.
  • For Promoting Interoperability (formerly Advancing Care Information), CMS eliminated the base, performance and bonus scores, and finalized a new scoring methodology,but maintains the "all-or-nothing" scoring. CMS will use performance-based scoring at the individual measure level. Each measure would be scored based on the performance on the measure on the submission of a numerator and a denominator, or yes or no. The scores for each individual measure would be added together to calculate the score of up to 100 possible points.

CMS is creating four overall objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. It is also adding two new measures to the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement.

CMS also finalized requiring MIPS-eligible clinicians to use 2015 Edition-certified Electronic Health Records (EHRs). Currently, clinicians can use 2014-certified systems to be eligible for the program.

Performance Period: The performance period for the Quality and Cost categories remains at the full performance year. It remains at 90 days for the Promoting Interoperability and Improvement Activities categories.

Low-Volume Threshold: To be excluded from MIPS, clinicians or groups would need to meet one of the following three criteria: have $90,000 or less in Part B allowed charges for covered professional services, provide care to 200 or fewer beneficiaries, or provide 200 or fewer covered professional services under the PFS (added criterion).

MIPS Payment Adjustment/Performance Threshold: The "performance threshold" represents the score that is necessary to receive a neutral to the positive payment adjustment for the year. A score below the performance threshold will result in a negative payment adjustment, while a score above the payment threshold will result in a positive payment adjustment. A score at the payment threshold will result in a neutral payment adjustment. CMS increased the performance threshold from 15 points to 30 points (out of 100). The exceptional performance threshold is set at 75 points, rather than the proposed 80 points, up from 70 points in 2018.

Expanding QPP Eligibility/Opt-In: CMS finalized an additional exclusion eligibility threshold for providers who do not submit at least 200 claims for the covered professional services under the PFS. CMS also said it would permit clinicians or groups who meet some but not all of these eligibility thresholds to opt-in to MIPS.

The agency also proposes expanding the types of clinicians eligible to participate in MIPS. Currently, five types of clinicians are eligible to participate: certified registered nurse anesthetists, clinical nurse specialists, nurse practitioners, physicians and physician assistants. Those clinicians could also qualify as part of a group. For 2019, CMS is expanding the eligibility pool to include physical therapists, occupational therapists, clinical psychologists, and registered dietitians or nutrition professionals.

Facility-Based Measurement: CMS finalized the implementation of a facility-based MIPS scoring that would allow "facility-based clinicians" to use the Hospital Value-Based Purchasing Program performance for the MIPS Quality and Cost categories. Clinicians who provide 75 percent or more of their services in an inpatient hospital, outpatient hospital or ED setting are eligible for facility-based measurement under MIPS.

New Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration: CMS finalized a five-year demonstration to test whether exempting clinicians who participate in certain Medicare Advantage payment arrangements would increase participation in Advanced APMs (AAPM). Participants who meet the requirements of this demonstration would automatically be exempt from MIPS, but would not receive the AAPM's 5 percent bonus.

Changes to Other Payer AAPM Criteria: CMS modified the Certified Electronic Health Record Technology (CEHRT) criteria for Other Payer AAPMs so that, beginning in 2020, 75 percent (instead of 50 percent) of eligible clinicians in other payer arrangements must use CEHRT. In addition, CMS finalized that in 2020 at least one of the quality measures used in other payer arrangements must be finalized on the MIPS final list of measures, endorsed by a consensus-based entity, or determined by CMS to be evidence-based, reliable and valid.  

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions