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The Daily Scan

Last Updated: 1:00 PM EST


  • Yesterday, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), announced and sought input on a new “International Pricing Index” (IPI) payment model to reduce what Americans pay for prescription drugs. Under the IPI model, described in an Advance Notice of Proposed Rulemaking (ANPRM), Medicare’s payments for select physician-administered drugs would shift to a level more closely aligned with prices in other countries. Overall savings for American taxpayers and patients are projected to total $17.2 billion over five years. The move from current payment levels to payment levels based on international prices would be phased in over a five-year period, would apply to 50 percent of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions. The model would correct existing incentives to prescribe higher-priced drugs and, for the first time, address disparities in prices between the United States and other countries. Since patient cost sharing is calculated based on Medicare’s payment amount, patients would see lower costs under the model. (HHS.gov)


  • On Wednesday, the federal Centers for Medicare and Medicaid Services (CMS) approved North Carolina's 1115 Demonstration Waiver application submitted November 2017. The approval is effective Jan. 1, 2019 through Oct. 31, 2024. Of note, CMS did not approve a section of the demonstration in which the state requested $45 million in federal funds to create an incentive program to fill gaps in its provider workforce which would pay off doctors' student loans in exchange for treating Medicaid beneficiaries. CMS claimed that there was not enough information provided at this time, and recommended that the state submit a demonstration amendment following the analysis and completion of a workforce development assessment. (NCDHHS.gov)


  • United States District Judge Jeffrey L. Schmehl entered a $3 million consent judgment against Melchor Martinez, Melissa Chlebowski, both of Allentown, PA, and their businesses, as follows: Northeast Community Mental Health Centers (in Philadelphia); Lehigh Valley Community Mental Health Centers (in Allentown, Easton, and Bethlehem); and Carolina Community Mental Health Centers (in Raleigh, North Carolina). The consent judgment was entered on October 18 as part of a settlement resolving a civil health care fraud lawsuit filed by the U.S. Attorney’s Office for the Eastern District of Pennsylvania under the False Claims Act. The institutional defendants are community mental health clinics that were funded largely by Medicaid and Medicare. Martinez was convicted of Medicaid fraud in 2000 by the Commonwealth of Pennsylvania. As a result, he was excluded from participating in all federally funded health care programs, including Medicaid and Medicare. The exclusion prohibited Martinez from owning, managing, or receiving payments from any federally funded health care provider. The United States alleged in the lawsuit that in spite of his exclusion, Martinez, assisted by his wife Chlebowski, continued to own and operate the Northeast and Lehigh Valley clinics, and that he started the Carolina clinic in Raleigh, North Carolina while his exclusion was ongoing in 2009. The United States alleged in its complaint that Chlebowski falsified Medicare and Medicaid enrollment applications by failing to disclose that Martinez, an excluded person, was managing the clinics, and that, as a result, all of the clinics’ Medicare and Medicaid claims were false. (Justice.gov)

  • Two Maryland women who were employed as personal care aides were arrested today on separate federal charges. Both are charged with engaging in a scheme in which they allegedly submitted a combined $1.7 million in false claims to the District of Columbia’s Medicaid program. According to the complaints, Temitope Oluwa-Bakare Ogunbiyi and Nkiru Uduji were employed as personal care aides from approximately January 2013 through the present. Under the Medicaid program, personal care aides perform services intended to assist Medicaid beneficiaries in carrying out the activities of daily living. To receive personal care services under Medicaid, a beneficiary must obtain a prescription from a doctor. An investigation determined that Ogunbiyi submitted approximately $1,071,247 in false claims between 2013 and the present, and Uduji submitted approximately $568,830, during the same time. The complaints allege that these claims fall into three categories: claims purporting that they provided services in excess of 24 hours in a given day; claims purporting that they provided services to Medicaid beneficiaries to whom they provided no care at all; and claims purporting that they provided services to Medicaid beneficiaries to whom they paid illegal kickbacks.Ogunbiyi is also alleged to have submitted claims for services purportedly provided to Medicaid beneficiaries while she was on international travel. (Justice.gov)

  • Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division yesterday announced the formation of the Appalachian Regional Prescription Opioid Strike Force (ARPO Strike Force), a joint law enforcement effort that brings together the resources and expertise of the Health Care Fraud Unit in the Criminal Division’s Fraud Section (HCF Unit), the U.S. Attorney’s Offices for nine federal districts in five states, as well as law enforcement partners at the FBI, U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) and U.S. Drug Enforcement Administration (DEA). The mission of the ARPO Strike Force is to identify and investigate health care fraud schemes in the Appalachian region and surrounding areas, and to effectively and efficiently prosecute medical professionals and others involved in the illegal prescription and distribution of opioids. The ARPO Strike Force will target criminal conduct associated with the improper prescription and distribution of prescription opioids and other dangerous narcotics throughout the Appalachian region and surrounding areas – focusing on criminal conduct by physicians, pharmacists, and other medical professionals. The ARPO Strike Force will also investigate and prosecute violations of health care fraud whenever such fraud is detected throughout the region. (Justice.gov)

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