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The Daily Scan

Last Updated: 1:00 PM EST

Medicare & Medicaid

  • Today, the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of the Treasury (collectively, the Departments) issued new guidance so states can move their insurance markets away from the one-size-fits-all rules and regulations imposed by the Affordable Care Act (ACA) and increase choice and competition within their insurance markets. The new guidance grants states more flexibility to design alternatives to the ACA and to give Americans more options to get health coverage that better meets their needs. Under this new policy, states will be able to pursue waivers to improve their insurance markets, increase affordable coverage options for their residents, and ensure that people with pre-existing conditions are protected. These waivers are called State Relief and Empowerment Waivers to reflect this new direction and opportunity. (CMS.gov: Press Release, Fact Sheet)

  • Last week, CMS staff detected anomalous activity in the Federally Facilitated Exchanges, or FFE’s Direct Enrollment pathway for agents and brokers. The Direct Enrollment pathway, first launched in 2013, allows agents and brokers to assist consumers with applications for coverage in the FFE. At this time, CMS believes that approximately 75,000 individuals’ files were accessed. “Our number one priority is the safety and security of the Americans we serve. We will continue to work around the clock to help those potentially impacted and ensure the protection of consumer information,” said CMS Administrator Seema Verma. “I want to make clear to the public that HealthCare.gov and the Marketplace Call Center are still available, and open enrollment will not be negatively impacted. We are working to identify the individuals potentially impacted as quickly as possible so that we can notify them and provide resources such as credit protection.” The tool through which the breach occurred is only available through the currently-disabled Direct Enrollment pathway for agents and brokers. As a result, the remaining FFE enrollment channels, including HealthCare.gov and the Marketplace Call Center, remain operational. (CMS.gov)

  • The Institute for Medicaid Innovation (IMI), the non-profit Medicaid research group, launched a first-of-its-kind national, longitudinal survey that collected information from Medicaid managed care organizations (MCOs) on seven critical health dimensions, demonstrating the capabilities of the industry in these areas. Especially noteworthy were the findings in high-risk care coordination, value-based payment models, women’s health, and behavioral health. Results in the high-risk care coordination domain showed that the majority of Medicaid MCOs performed a common set of core functions like developing a plan of care for members, supporting adherence to that plan of care, using a care team to address member needs, and conducting risk assessments. On value-based payment, the survey found that a majority of Medicaid MCOs are using VBP models more and more when providing care for their members. Regarding women’s health, findings showed that although many women’s health issues were not seen as being a significant need among members, most MCOs still offered programs and engagement strategies in women’s health. Finally, behavioral health’s integration with physical health emerged as a key challenge for Medicaid MCOs, with top barriers being limitations on the sharing of substance use disorder treatment information, access to behavioral health providers in select regions (e.g., rural), and access to data between care management and behavioral health teams. (MedicaidInnovation.org)


  • Iowa Governor Kim Reynolds said she believes contraception should be available to Iowa women through pharmacies and without prescriptions. Reynolds, a Republican who is currently seeking election to a full term, first unveiled the policy proposal without much fanfare at a gubernatorial debate with Democrat Fred Hubbell Wednesday night in Sioux City. "I think this is another opportunity for us to help with access, especially in rural Iowa, and to give more choices when it comes to family planning," Reynolds told the Des Moines Register in a follow-up interview. "I think this is the direction we should go. I think by eliminating some of the barriers and making it available through a pharmacist, it will help reduce the rate of unintended pregnancies and abortions." (DesMoinesRegister.com)

  • Thousands of uninsured Floridians are eligible for no-cost replacements of critical medications lost or damaged by Hurricane Michael. This relief comes from the Emergency Prescription Assistance Program (EPAP), managed by the U.S. Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR). The program pays for prescription medications for people without health insurance who are affected by disasters. More than 4,900 Florida pharmacies participate in EPAP, and more than 72,000 pharmacies participate nationwide. At no cost to uninsured patients, those needing certain prescription medications during an emergency can obtain a 30-day supply at any EPAP participating pharmacy through Nov. 15. Most prescription drugs are available. Uninsured patients also may use the program to replace specific medical supplies, vaccines or medical equipment, such as canes and walkers, damaged or lost as a direct result of Hurricane Michael or as a secondary result of loss or damage caused while in transit from the emergency site to an emergency shelter. (HHS.gov)


  • The government filed a complaint in a False Claims Act lawsuit against Aarti D. Pandya, an ophthalmologist from Conyers, Georgia, and her practice Aarti D. Pandya, M.D., P.C. The lawsuit alleges that the defendant submitted false claims to Medicare for surgical procedures, diagnostic tests, and office visits that were medically unnecessary, of worthless value, upcoded, and in some cases, not provided at all. The government’s complaint alleges that, between January 1, 2011 and December 31, 2016, Dr. Pandya engaged in multiple schemes to submit false claims to Medicare, including claims for medically unnecessary cataract extraction surgery. Cataract surgery is only justified when a patient has a cataract that advances to the point where the patient cannot see well enough to carry out their normal daily activities. In many cases, Dr. Pandya performed surgery despite the fact that her patients had little to no vision complaints and normal visual acuity. She also failed to determine whether the patient would benefit from less invasive measures, such as glasses, as is required before submitting Medicare claims for cataract surgery. The complaint also alleges that Dr. Pandya rendered false glaucoma diagnoses, which she used to submit a battery medically unnecessary diagnostic tests to Medicare. (Justice.gov)

  • Dr. Devon Golding was convicted by a jury today in U.S. District Court in St. Louis, MO for participating in a conspiracy to commit health care fraud and four substantive counts of health care fraud. Dr. Golding’s trial took place before Judge Audrey G. Fleissig, who ordered a presentence report and set a sentencing hearing for January 29, 2019. The jury found that Dr. Golding and other doctors solicited and received illegal kickbacks from Allegiance Medical Services, a clinical laboratory, in return for referring and sending blood and urine specimens to Allegiance for testing. Allegiance then billed Medicare and Medicaid for the testing of the specimens and gave Dr. Golding and other doctors kickbacks, derived from the payments received from Medicare and Medicaid. Golding knew that Medicare and Medicaid would not pay for any service provided in violation of the federal Anti-Kickback Statute. In 2015, Dr. Golding was convicted of health care fraud and false statements in connection with another scheme in which he improperly billed Medicare and Medicaid for non-rendered physician services and also signed blank prescription pads on which he permitted a non-qualified nurse to write prescriptions for controlled substances. (Justice.gov)

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