The Daily Scan

September 28, 2018

Last Updated: 1:15 PM EST

Litigation

  • A Detroit-area doctor was sentenced to 135 months in prison yesterday for her role in a scheme involving approximately $8.9 million in fraudulent Medicare claims for home health care and other physician services that were procured through the payment of kickbacks, were not medically necessary, were not actually provided or, in some instances, were provided by the defendant, who was not a licensed physician during the relevant time period. To make it appear that these services were medically necessary and actually provided, Traylor and her co-conspirators falsified medical records and signed false documents. Additionally, the evidence at trial showed that Traylor and her co-conspirators paid and received kickbacks in exchange for referring Medicare beneficiaries to serve as patients at the clinics. The trial evidence also revealed that Traylor fraudulently signed the names of licensed physicians on prescriptions for opioid medications, such as oxycodone, as a means of inducing patient participation in the scheme. (Justice.gov)

Legislation

  • The House voted overwhelmingly on Friday in favor of a bill that sets new policies and reauthorizes hundreds of billions of dollars in federal grants in a bid to fight America's opioid epidemic. The SUPPORT for Patients and Communities Act passed easily in a 393-8 vote, and will head to the Senate, where it is expected to be approved and then will head to President Trump’s desk. The legislation is a combination of bills that the House passed in June and a major package the Senate passed last week. Of note, the legislation requires Medicaid to cover all types of medication assisted treatment used to treat addiction, which include buprenorphine and methadone. Currently, under Medicaid rules, hospitals cannot allow more than 16 patients with mental illnesses or addictions to stay at the hospital. Going over this limit endangers Medicaid reimbursements for the facility. (WashingtonExaminer.com)

Regulation

  • Eli Lilly and Company announced today that the U.S. Food and Drug Administration (FDA) has approved Emgality™ (galcanezumab-gnlm) 120 mg injection for the preventive treatment of migraine in adults. Emgality offers a once-monthly, self-administered, subcutaneous injection. Emgality is contraindicated in patients with serious hypersensitivity to galcanezumab-gnlm or to any of the excipients. Patients with commercial insurance are candidates to receive Emgality for up to 12 months free as part of Lilly's patient support program (governmental beneficiaries excluded; subject to terms and conditions*). Emgality will be available for pickup at retail pharmacies. Migraine is a disabling, neurologic disease that affects more than 30 million American adults. According to the Medical Expenditures Panel Survey, the total unadjusted cost associated with migraine in the U.S. is estimated to be as high as $56 billion annually, yet migraine remains under-recognized and under-treated. Current HHS Secretary Alex Azar is the former president of Eli Lilly USA. (Investor.Lilly.com)

Medicare & Medicaid

  • The Centers for Medicare and Medicaid Services (CMS) today released the 2019 Medicare Advantage and Part D Landscape Fact Sheet, which provides important premium and cost sharing information for Medicare health and drug plans offered in 2019. Of note, the data reveals that enrollment in Medicare Advantage is projected to be at an all-time high in 2019 with 22.6 million Medicare beneficiaries. This represents a projected 2.4 million (11.5 percent) increase from 20.2 million in 2018. Based on projected enrollment, 36.7% of Medicare beneficiaries will be enrolled in Medicare Advantage in 2019. Additionally, Medicare Advantage premiums, on average, have steadily declined since 2015 from the actual average premium of $32.91. For 2019, CMS estimates the Medicare Advantage average monthly premium will decline by $1.81 to $28.00 from 2018. (CMS.gov)

 

  • In a speech in Nashville, TN yesterday, HHS Secretary Alex Azar made the following comments about "Medicare for All": "When you drill down into the details, it’s clear that Medicare for all is a misnomer. What’s really being proposed is a single government system for every American that won’t resemble Medicare at all...The main thrust of Medicare for all is giving you a new government plan and taking away your other choices...The president who was supposedly trying to sabotage the Affordable Care Act has proven better at managing it than the president who wrote the law." (TheHill.com)

Private Sector

  • Health IT company Athenahealth has received and is weighing multiple takeover bids, sources told CNBC yesterday. The bids are not seen as being far above the stock price of $131, but the Athenahealth board is motivated to get a deal done, and interest is coming from two private equity firms and one strategic buyer, the sources said. Paul Singer's Elliott Management previously had bid $160 a share for the health-care software maker in an all-cash unsolicited offer. That put pressure on the company to consider strategic options. In June 2018, Jonathan Bush stepped down as Athenahealth CEO and the company initiated a strategic review, which culminated with an announcement that it would consider a sale or merger or remaining as an independent company. (CNBC.com)

 

 

 

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