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The Daily Scan

Last Updated: 1:00 PM EST

Medicare & Medicaid

  • The Centers for Medicare & Medicaid Services proposed yesterday to require that prescription drug manufacturers post the Wholesale Acquisition Cost (WAC) for drugs covered in Medicare or Medicaid in direct-to-consumer television advertisements. The proposed rule would work to inject greater transparency into the prices prescription drug manufacturers set and would give beneficiaries important information they need to make informed decisions based on cost, while concurrently providing a moderating force to counteract price increases. Under the proposed rule, the price required to be posted would be for a typical course of treatment for an acute medication like an antibiotic, or a thirty day supply of medication for a chronic condition that is taken every month, and the posting would take the form of a legible textual statement at the end of the ad. The HHS Secretary would maintain a public list of drugs that were advertised in violation of this rule, and CMS would provide an exception to the requirement to post prices for prescription drugs with list prices of less than $35 per month. (Proposed Rule: FederalRegister.gov; Press Release: CMS.gov)

  • Former Maine health commissioner and Republican gubernatorial candidate Mary Mayhew has been tapped by the Trump administration to lead Medicaid, the health insurance program that covers more than 70 million low-income Americans. CMS Administrator Seema Verma said in a prepared statement Monday that Mayhew has been named deputy administrator of the centers, and director of Medicaid. She also will oversee the Children’s Health Insurance Program. The two programs cost more than $350 billion annually, or about 10% of the entire federal budget. Mayhew is best known for her seven years as commissioner of the Maine Department of Health and Human Services under Gov. Paul LePage. During her tenure, she oversaw major changes to nearly all of Maine’s public assistance programs, including food stamps and the Temporary Assistance for Needy Families program. Mayhew also played a major role in eliminating nearly 70,000 people from the state’s Medicaid program and, like LePage, she was an ardent opponent of expanding Medicaid, which was made allowable at the state level under the Affordable Care Act. (PressHerald.com)

  • The Government Accountability Office (GAO) released a new Medicaid report yesterday titled: "Access to Health Care for Low-Income Adults in States with and without Expanded Eligibility." GAO was asked to provide information about the demographic characteristics of and access to health care services for low-income adults—those with household incomes less than or equal to 138 percent of the federal poverty level—in expansion and non-expansion states. This report describes 2016 national survey estimates of (1) the number and demographic characteristics for low-income adults who were uninsured in expansion and non-expansion states, (2) unmet medical needs for low-income adults in expansion and non-expansion states and by insurance status, (3) barriers to health care for low-income adults in expansion and non-expansion states and by insurance status, and (4) having a usual place of care and receiving selected health care services for low-income adults in expansion and non-expansion states and by insurance status. (GAO.gov)

  • President Donald Trump tweeted yesterday evening: "Open enrollment starts today on lower-priced Medicare Advantage plans so loved by our great seniors. Crazy Bernie and his band of Congressional Dems will outlaw these plans. Disaster!" (Twitter.com)


  • Anthem, Inc. has agreed to pay $16 million to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) and take substantial corrective action to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules after a series of cyberattacks led to the largest U.S. health data breach in history and exposed the electronic protected health information of almost 79 million people. The $16 million settlement eclipses the previous high of $5.55 million paid to OCR in 2016. Anthem is an independent licensee of the Blue Cross and Blue Shield Association operating throughout the United States and is one of the nation’s largest health benefits companies, providing medical care coverage to one in eight Americans through its affiliated health plans. This breach affected electronic protected health information (ePHI) that Anthem, Inc. maintained for its affiliated health plans and any other covered entity health plans. On March 13, 2015, Anthem filed a breach report with the HHS Office for Civil Rights detailing that, on January 29, 2015, they discovered cyber-attackers had gained access to their IT system via an undetected continuous and targeted cyberattack for the apparent purpose of extracting data, otherwise known as an advanced persistent threat attack. After filing their breach report, Anthem discovered cyber-attackers had infiltrated their system through spear phishing emails sent to an Anthem subsidiary after at least one employee responded to the malicious email and opened the door to further attacks. OCR’s investigation revealed that between December 2, 2014 and January 27, 2015, the cyber-attackers stole the ePHI of almost 79 million individuals, including names, social security numbers, medical identification numbers, addresses, dates of birth, email addresses, and employment information.

  • A health care CEO pleaded guilty yesterday to a superseding indictment as part of an investigation into a $300 million health care fraud scheme that involved the distribution of over 6.6 million dosage units of controlled substances and the administration of medically unnecessary injections that resulted in patient harm. Mashiyat Rashid, of West Bloomfield, Michigan, was the CEO of the Tri-County Wellness Group of medical providers in Michigan and Ohio, and pleaded guilty to one count of conspiracy to commit health care fraud and wire fraud, and one count of money laundering. In connection with his plea agreement, Rashid agreed to the entry of a forfeiture money judgment in the amount of $51,396,917.70, as well as forfeiture to the United States of property traceable to proceeds of the health care fraud scheme, including over $11.5 million, commercial real estate, residential real estate, and a Detroit Pistons season ticket membership. (Justice.gov)

  • On October 12, 2018, the District Court for the Eastern District of Tennessee unsealed a 32-count indictment charging four individuals and seven companies in a $1 billion health care fraud scheme. The court also unsealed an additional two plea agreements and an information charging another individual and his company for their role in the scheme. All the defendants were charged with conspiracy to commit health care fraud, mail fraud, and introducing misbranded drugs into interstate commerce. The indictment alleges that from June 1, 2015 through April 1, 2018, these individuals and companies, together with other persons and companies known to the grand jury, conspired to deceive tens of thousands of patients and more than 100 doctors located in the Eastern District of Tennessee and across the country for the purpose of defrauding private health care benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174,000,000. The indictment further alleges that the defendants submitted not less than $931,000,000 in fraudulent claims for payment. According to the indictment, the defendants set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products. The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers. (Justice.gov)

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