The Daily Scan

September 19, 2018

Last Updated: 1:10 PM EST

Litigation

  • Insurance Commissioner Dave Jones filed an insurance-fraud complaint yesterday in Alameda County Superior Court on behalf of the State of California against AbbVie Inc. alleging AbbVie gave illegal kickbacks to health care providers to prescribe HUMIRA—an expensive and dangerous drug with potentially deadly side effects. The case alleges that private insurers have paid out $1.2 billion in HUMIRA-related pharmacy claims, making this the largest health insurance fraud case in department history. According to the complaint, AbbVie engaged in a far-reaching scheme including both classic kickbacks—cash, meals, drinks, gifts, trips, and patient referrals—and more sophisticated ones—free and valuable professional goods and services to physicians to induce and reward HUMIRA prescriptions. These professional goods and services included free insurance processing and prior authorizations, gifts of medical practice management hardware and software, and even marketing assistance, all of which save physicians valuable staff time and resources. "AbbVie spent millions convincing patients and health care professionals that AbbVie Ambassadors were patient advocates—in fact, the Ambassadors were HUMIRA advocates hired to do one thing, keep patients on a dangerous drug at any cost," said Insurance Commissioner Dave Jones. (Insurance.CA.gov)

 

 

  • Terri C. Brown, the former owner of a Bridgeville, PA Suboxone clinic, pled guilty in federal court yesterday to charges of unlawfully distributing controlled substances and health care fraud. In connection with the guilty plea, the court was advised that Brown owned and operated Cherry Way, a Suboxone clinic, located in Bridgeville PA, and her co-defendant, Dr. Mark Foster was a medical director at Cherry Way. Brown and Foster conspired together to create and submit unlawful prescriptions for Suboxone, Adderall and Percocet, and then unlawfully dispensed those controlled substances. Brown also committed health care fraud by submitting fraudulent claims to Highmark and Medicaid, through Cherry Way, for payments to cover the costs of the unlawfully prescribed Suboxone, Adderall and Percocet. (Justice.gov)

 

  • Dr. Jayam Krishna Iyer of Clearwater, FL pled guilty yesterday to one count of health care fraud. She faces a maximum penalty 20 years in federal prison if her offense involves serious bodily injury. As part of the plea, Iyer has agreed to surrender both her DEA registration number that she used to prescribe controlled substances and her Florida medical license, and to a permanent exclusion from the Medicare and Medicaid programs. Beginning at least as early as July 2011, and continuing through December 2017, Iyer executed and carried out a scheme to defraud Medicare by billing for face-to-face office visits with Medicare beneficiaries, when, in fact, certain patients did not go to Iyer’s office and were not examined by her on the claimed dates; instead, family members of the patients went to Iyer’s office with notes requesting that Iyer issue and provide prescriptions, including for Schedule II controlled substances like oxycodone, to the family members, and in the beneficiaries’ names—and Iyer issued those prescriptions. Iyer thereby violated a Florida law requiring doctors to perform an in-person office visit and examination of each patient before issuing Schedule II controlled substance prescriptions. Iyer also falsified her electronic medical records, including vital statistics, to make it appear that the actual patient was present in her office for an office visit, when the patient was not. Iyer submitted at least $51,500 in these types of false and fraudulent Medicare claims. (Justice.gov)

Medicaid

  • In a letter sent September 14, an advocacy group for low-income Maine residents urged the U.S. Centers for Medicare and Medicaid Services to disregard a letter from Gov. Paul LePage asking the agency to reject the state’s plan for expanding Medicaid. “Expanding the Medicaid program is by federal law a step that Maine is entitled to take, and the choice to take that step is now the established law of the state of Maine,” wrote Charles Dingman, an attorney representing Maine Equal Justice Partners, the advocacy group that sued the LePage administration for failing to implement expansion. LePage – a staunch opponent of expansion – submitted a State Plan Amendment in September to the federal agency after he was ordered by a court to do so, but at the same time he asked the federal government to reject the plan. (PressHerald.com)

Research

  • On Monday, the Office of the Chief Technology Officer published a comprehensive report of the data sharing environment at the U.S. Department of Health & Human Services (HHS). The report explores the challenges of sharing data between HHS agencies. Led by HHS Chief Data Officer Dr. Mona Siddiqui, a small team of HHS staff interviewed agency leadership and staff from eleven HHS agencies, including at the NIH, CDC, FDA, CMS, and AHRQ, about the challenges and opportunities in sharing data between agencies. This report focuses specifically on data assets identified by the agencies as having high value and that are restricted or nonpublic. The report is part of an ongoing effort to build and implement an enterprise-wide data strategy at HHS. According to the report, HHS lacks a consistent, transparent, and standardized protocol for interagency data sharing. While there are project-by-project successes, there is significant opportunity to develop a framework to efficiently scale. The report also outlines legal, technical, and cultural challenges. (HHS.gov)

 

 

 

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