Last Updated: 1:00 PM EST
Premier Surgical Pavilion, an ambulatory surgical center in Newark, NJ, has filed a complaint against Horizon Blue Cross Blue Shield of New Jersey in New Jersey Federal Court. The complaint references two counts: Claim for Benefits Under ERISA § 502(a)(1)(B) and Claim For Breach of Fiduciary Duty Under ERISA § 502(a)(2). PSP alleges that they have been denied meaningful access to a full and fair review of its claims under ERISA, as well as the Plans’ administrative procedures and remedies.
Sheetal Kanar Kumar, M.D. of Stuart, FL appeared in federal court on Friday and was arraigned on twenty-six counts of health care fraud (Case No. 18-14063-CR-Marra). According to the indictment, Dr. Kumar owned and operated the medical practice Advanced Healthcare for Women in Stuart, Florida. She was an obstetrician and gynecologist licensed to practice medicine. She also provided medical services treating incontinence. From at least as early as January 2014, until July 2017, Dr. Kumar submitted or caused the fraudulent submission of claims to Medicare, Medicaid and private insurance companies. The fraudulent claims sought money for specific health care benefits, items, and services that were not provided as billed. As a result of such false and fraudulent claims, Medicare, Medicaid and private insurance companies, made payments in the approximate amount of $926,802. (Justice.gov)
Pennsylvania and seven major health insurance companies (Aetna, Capital Blue Cross, Geisinger, Highmark, Independence Blue Cross, UPMC and United Healthcare) reached an agreement on Friday to remove prior authorization requirements for opioid treatment. Under the agreement, insurers committed to remove prior authorization for substance use disorder treatment and include various medicines to treat substance use disorders on the lowest cost-sharing tier of a health plan's pharmacy benefit, according to the American Medical Association and Pennsylvania Medical Society. The prior authorization process requires patients, physicians or other healthcare providers to get advance insurer approval to be eligible for payment before a patient receives a specific service. By removing prior authorization for opioid treatment, thousands of lives could potentially be saved, according to the AMA and Pennsylvania Medical Society. (BeckersHospitalReview.com)
On Friday, the U.S. Food and Drug Administration sent letters to 21 e-cigarette companies, including the manufacturers and importers of Vuse Alto, myblu, Myle, Rubi and STIG, seeking information about whether more than 40 products – including some flavored e-cigarette products – are being illegally marketed and outside the agency’s current compliance policy. These new actions build on those taken by the FDA in recent weeks as part of its Youth Tobacco Prevention Plan to address the epidemic of youth e-cigarette use, including cracking down on the sale and marketing of e-cigarettes to kids and educating youth about the dangers of using these products. "Companies are on notice – the FDA will not allow the proliferation of e-cigarettes or other tobacco products potentially being marketed illegally and outside of the agency’s compliance policy, and we will take swift action when companies are skirting the law," said FDA Commissioner Scott Gottlieb, M.D. (FDA.gov)
Medicare Open Enrollment for 2019 begins today, October 15 and runs through through December 7. (Medicare.gov)
Zimmer Biomet Holdings, Inc., a global leader in musculoskeletal healthcare, announced today that it is working with Apple by using Apple Watch and iPhone to change the patient journey for two of the most common surgeries Americans undergo each year – knee and hip replacement. This collaboration has yielded Zimmer Biomet mymobility™, an app that uses Apple Watch to facilitate a new level of connection between patients and their surgical care teams, which can immediately impact the journey patients experience when they undergo these procedures. In addition to the app, Zimmer Biomet is commencing the mymobility Clinical Study, designed to study the app's impact on patient outcomes and overall costs for joint replacement patients. During this research study, patients will use Zimmer Biomet mymobility with Apple Watch as they progress through their hip or knee replacement journey. Researchers will combine patient-reported feedback with continuous health and activity data from Apple Watch to provide new insights into the power of the Zimmer Biomet mymobility app to impact the standard of care for these common surgeries. The study is launching today and has the possibility to enroll as many as 10,000 patient participants in the United States. "We are incredibly excited to work with Apple to transform the knee and hip replacement experience for patients and surgeons," said Bryan Hanson, President and CEO, Zimmer Biomet. (ZimmerBiomet.com)