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The Daily Scan

Last Updated: 8:55 AM EST


  • The United States District Court for the District of Columbia issued an opinion on Friday granting UnitedHealthcare’s Motion for Summary Judgment in UnitedHealthcare Insurance Co. v. Azar, No. 16-157 (D.D.C.), which challenged CMS’ 2014 Overpayment Rule (the “Rule”). Judge Collyer’s decision vacated the Rule in its entirety, finding that, by effectively imposing a 100% accuracy requirement on the data that Medicare Advantage organizations (“MAOs”) report to CMS for risk adjusted payment purposes, the Rule violated the statutory mandate of “actuarial equivalence” between CMS payments for healthcare coverage under traditional Medicare and Medicare Advantage (“MA”). Moreover, the Court found that the Rule’s facilitation of False Claims Act liability for MAOs’ failures to engage in “reasonable diligence” overshot CMS’ statutory authority, and that its definition of when an overpayment is “identified” was finalized without adequate notice as required by the Administrative Procedure Act. (Lexology.com)

  • A federal jury found a South Florida pharmacist guilty today of health care fraud for his role in a $5 million compounding pharmacy scheme. After a four-day trial, Stephen Chalker was convicted of one count of conspiracy to commit health care fraud and two substantive counts of health care fraud. From approximately September 2014 to August 2016, Chalker engaged in a scheme to defraud Medicare, TRICARE and Medicaid by submitting false and fraudulent claims for compounded drugs and other prescription medications that were not medically necessary and/or never provided. The evidence established that in his role as the pharmacist-in-charge at Pop’s Pharmacy, a now-defunct pharmacy located in Deerfield Beach, Florida, Chalker submitted or caused the submission of claims in the amount of several thousands of dollars each for a single tube of pain and scar creams that patients did not want, did not need, and in some cases did not receive. Chalker and his co-conspirators ran a nationwide telemarketing and telemedicine scheme in which there was no real patient-prescriber relationship or actual patient care. As a result of claims submitted in connection with the scheme, Medicare, TRICARE and Medicaid made payments totaling nearly $5 million, the evidence showed. (Justice.gov)


  • Former President Obama on Friday called "Medicare for all" a "good" idea during a speech in Illinois where he launched his midterm campaign efforts for Democrats. "Democrats aren't just running on good, old ideas like a higher minimum wage. They're running on good, new ideas like Medicare for all," Obama said. (TheHill.com)


  • The Government Accountability Office (GAO) released a new report on Thursday titled "Nursing Home Quality: Continued Improvements Needed in CMS’s Data and Oversight." GAO’s October 2015 report found mixed results in nursing home quality based on its analysis of trends reflected in key sources of quality data that the Centers for Medicare & Medicaid Services (CMS) collects. Although CMS and others have reported some potential improvements in nursing home quality, questions have been raised about nursing home quality and weaknesses in CMS oversight. This new report describes trends in nursing home quality through 2014, and changes CMS had made to its oversight activities as of October 2015. It also includes the status of GAO’s recommendations associated with these findings. GAO recently obtained information from CMS officials about steps they have taken to implement the 2015 GAO recommendations. (GAO.gov)

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