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The Daily Scan

Last Updated: 1:00 PM EST


  • The Department of Justice announced today that it is requiring CVS Health Corporation (CVS) and Aetna Inc. (Aetna) to divest Aetna’s Medicare Part D prescription drug plan business for individuals in order to proceed with their $69 billion merger. The proposed divestiture to WellCare Health Plans, Inc. (WellCare), an experienced health insurer focused on government-sponsored health plans, including Medicare Part D individual prescription drug plans, would fully resolve the Department’s competition concerns. “Today’s settlement resolves competition concerns posed by this transaction and preserves competition in the sale of Medicare Part D prescription drug plans for individuals,” said Assistant Attorney General Makan Delrahim of the Justice Department’s Antitrust Division. “The divestitures required here allow for the creation of an integrated pharmacy and health benefits company that has the potential to generate benefits by improving the quality and lowering the costs of the healthcare services that American consumers can obtain.” (Justice.gov, CVSHealth.com)

  • Starsky Bomer of Harris County, Texas, was convicted by a grand jury on Friday of one count of conspiracy to pay and receive healthcare kickbacks, two counts of violating the Anti-Kickback Statute, and one count of conspiracy to commit health care fraud following a five-day trial. Sentencing has been scheduled for January 2019. According to evidence presented at trial, from 2011 until February 2013, Bomer and others engaged in a scheme to defraud Medicare by submitting to Medicare, through Atrium Medical Center (Atrium) and Pristine Healthcare (Pristine), approximately $16 million in false and fraudulent claims for partial hospitalization program (PHP) services. A PHP is a form of intensive outpatient treatment for severe mental illness. The evidence presented at trial showed that Bomer, the hospitals’ chief financial officer and chief operating officer, orchestrated a scheme by which he and others paid illegal bribes and kickbacks to group home owners and patient recruiters in exchange for sending Medicare patients to Atrium and Pristine’s PHPs. (Justice.gov)

  • The owner of a Miami-area pharmacy pleaded guilty for his role in Medicare prescription fraud scheme involving approximately $8.4 million in fraudulent billings. Antonio Perez Jr. pleaded guilty to agreeing to pay illegal health care kickbacks to Medicare beneficiaries in exchange for a promise from the beneficiaries to fill their prescriptions at Valles Pharmacy which he owned, and to allow Valles Pharmacy to submit claims to Medicare for prescription drugs that were not provided to the beneficiaries. Perez Jr. also admitted that he submitted claims to Medicare for expensive prescription medications that Valles Pharmacy never purchased, and were never provided to Medicare beneficiaries. According to admissions made in connection with Perez Jr.’s plea, during the course of the scheme, Valles Pharmacy Discount submitted over $32 million in claims to Medicare for prescription drugs, of which approximately $8.4 million was for medically unnecessary prescription drugs that Valles Pharmacy never purchased, and were never provided to Medicare beneficiaries. The case was investigated by the FBI and HHS-OIG, and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Southern District of Florida. (Justice.gov)

Medicare & Medicaid

  • Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced that 1,299 entities have signed agreements with the agency to participate in the Administration’s Bundled Payments for Care Improvement – Advanced (BPCI Advanced) Model. The participating entities will receive bundled payments for certain episodes of care as an alternative to fee-for-service payments that reward only the volume of care delivered. The Model participants include 832 Acute Care Hospitals and 715 Physician Group Practices – a total of 1,547 Medicare providers and suppliers, located in 49 states plus Washington, D.C. and Puerto Rico. Of note, BPCI Advanced qualifies as an Advanced Alternative Payment Model (Advanced APM) under MACRA, so participating providers can be exempted from the reporting requirements associated with the Merit-Based Incentive Payment System (MIPS). “To accelerate the value-based transformation of America’s healthcare system, we must offer a range of new payment models so providers can choose the approach that works best for them,” said CMS Administrator Seema Verma. (CMS.gov)

  • The Hill reported this morning that the Trump Administration is planning 60 hours of downtime for maintenance on Healthcare.gov during the upcoming Affordable Care Act sign-up period. The maintenance schedule is the same as last year, the federal Centers for Medicare and Medicaid Services said Tuesday, meaning Healthcare.gov is scheduled to be offline for maintenance from 12 a.m. to 12 p.m. each Sunday during the sign-up period, except for the final Sunday. Officials said that is the maximum possible downtime, and said last year the actual downtime was significantly less than what was scheduled, at 21.5 hours out of a scheduled 60. The coming sign-up period, for 2019 coverage, runs from Nov. 1 to Dec. 15. (TheHill.com)


  • Yesterday U.S. Senator Tammy Baldwin filed a discharge petition that will force a Senate vote on her resolution to overturn the Trump Administration’s expansion of junk insurance plans that can deny coverage to people with pre-existing conditions and don’t have to provide essential health services like prescription drugs, emergency room visits and maternity care. The Senate vote on overturning the expansion of junk insurance plans is expected to take place today. Last week, Senator Baldwin announced that 49 Senators will vote in favor of her resolution, so just two Republican votes are needed for it to pass the Senate. “The Trump Administration is rewriting the rules on guaranteed health care protections that millions of Americans depend on. These junk insurance plans can deny coverage to people with pre-existing conditions and don’t have to provide essential health services like prescription drugs, emergency room visits and maternity care,” said Senator Baldwin. “Anyone who says they support health care coverage for people with pre-existing conditions should support this resolution. This is an opportunity for Democrats and Republicans to protect people’s access to quality, affordable health care when they need it most.” Senator Baldwin’s effort is supported by more than 20 of the nation’s top health care organizations. (Baldwin.Senate.gov)

#Legislation #Litigation #Medicaid #Medicare


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