The Daily Scan

August 14, 2018

Last Updated: 8:50AM EST 

Litigation

  • Newark/Philadelphia Medicare Fraud Strike Force has been formed as announced by Assistant Attorney General  Brian A. Benczkowski of the Justice Department’s Criminal Division. This is a joint law enforcement effort that brings together the resources and expertise of the Health Care Fraud Unit in the Criminal Division’s Fraud Section (HCF Unit), the U.S. Attorney’s Offices for the District of New Jersey and the Eastern District of Pennsylvania, as well as law enforcement partners at the FBI, U.S. Department of Health and Human Services Office of the Inspector General and U.S. Drug Enforcement Administration.  Assistant Attorney General Benczkowski commented,  “the devastation the opioid epidemic is inflicting on communities across the country and here in the Mid-Atlantic region is staggering and health care fraud has played a role in feeding that epidemic, it is estimated that each year tens of billions of dollars in American taxpayer money are lost to fraud, waste, abuse and improper payments.  According to the CDC, in 2016, more than 40 percent of all U.S. opioid overdose deaths involved a prescription opioid.  Our Medicare Fraud Strike Forces, which we have now expanded into Newark and Philadelphia, constitute one of our most important and effective means for containing these threats to the American people.” (Justice.gov

Regulation

  • The Office of the Inspector General of Health and Human Services conducted a review to determine whether CMS accurately authorized financial assistance payments in accordance with Federal requirements for policies associated with individuals enrolled in qualified health plans (QHPs) operating through the Federal marketplace. The OIG found that of the 140 policies in our sample, CMS accurately authorized financial assistance payments for 109 policies; however, financial assistance payments for 26 policies were not accurately authorized in accordance with Federal requirements. For the remaining five policies, CMS authorized potentially improper financial assistance payments to QHP issuers that did not provide documentation to support that enrollees had paid their premiums, a requirement for receiving these payments. The OIG has recommended that CMS work with the U.S. Department of the Treasury and QHP issuers to collect improper financial assistance payments, that the OIG estimates to be almost $434.4 million. (OIG.HHS.gov)

  • After review by the Office of the Inspector General of Health and Human Services, Alaska was found to have received millions in unallowable bonus payments. Some of the bonus payments that Alaska received for the audit period were not allowable in accordance with Federal requirements. Alaska overstated its fiscal years 2009 through 2013 current enrollment in its bonus requests to CMS because it included individuals who did not qualify because of their basis-of-eligibility (BOE) category. The OIG has recommended that Alaska refund almost $8.9 million to the federal government. (OIG.HHS.gov)

  • The U.S. Food and Drug Administration has approved Galafold, a new treatment for a rare genetic disorder called, Fabry disease. Galafold is the first oral medication for the treatment of adults with Fabry disease. The drug is indicated for adults with Fabry disease who have a genetic mutation determined to be responsive to treatment with Galafold based on laboratory data. The FDA commented, "the efficacy of Galafold was demonstrated in a six-month, placebo-controlled clinical trial in 45 adults with Fabry disease. In this trial, patients treated with Galafold over six months had a greater reduction in globotriaosylceramide (GL-3) in blood vessels of the kidneys as compared to patients on placebo. The safety of Galafold was studied in four clinical trials which included a total of 139 patients with Fabry disease." (FDA.gov

Research

  • An analysis released yesterday by, Peterson-Kaiser Health System Tracker (The Kaiser Family Foundation), noted that about 1 in 6 hospital stays for patients enrolled in large employer health plans results in out-of-network bills, which tend to be costly and not fully covered by insurance. The study took medical bills from large employer plans and found that 18% of inpatient admissions result in out-of-network claims. The bills arise when a patient goes to an in-network hospital, but receives care from a medical professional who is out-of-network. The study wrote, "enrollees can face higher, sometimes much higher, out-of-pocket costs when they receive care from providers that are not in their plans’ provider networks. Out-of-network care might not be covered at all if the patient is enrolled in a health maintenance organization (HMO) or exclusive provider organization (EPO) plan, which only cover non-emergency services in network." (HealthSystemTracker.org)

 

 

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