The Weekly Scan

December 14, 2018

Last Updated: 1:00 PM EST

Medicaid

  • The Arkansas Department of Human Services (DHS) announced on Wednesday that starting December 19, Arkansas Works enrollees who need to report their work and community engagement activities will have more options to do so by phone with the launch of a new DHS Helpline. That means Arkansas Works enrollees can report by phone by calling the DHS Helpline, their insurance carrier, or a trusted friend or Registered Reporter. Enrollees also can report online and in-person at a DHS county office. “We are six months into this new Medicaid demonstration program, but wanted to take the time now to assess what areas we need to shore up or improve,” said DHS Director Cindy Gillespie. “Though enrollees have had the ability to report by phone through carriers, friends, and registered reporters, we felt it was important to expand that option before we roll the next group into the work and community engagement requirement. ”Though we have seen improvement in the percentage of current enrollees who are meeting the requirement, Gillespie said the State wants to see those percentages increase. (HumanServices.Arkansas.gov)

Regulation

  • On Tuesday, Pagosa Springs Medical Center (PSMC) agreed to pay $111,400 to the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services and to adopt a substantial corrective action plan to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules. PSMC is a critical access hospital, that at the time of OCR’s investigation, provided more than 17,000 hospital and clinic visits annually and employs more than 175 individuals. The settlement resolves a complaint alleging that a former PSMC employee continued to have remote access to PSMC’s web-based scheduling calendar, which contained patients’ electronic protected health information (ePHI), after separation of employment. OCR’s investigation revealed that PSMC impermissibly disclosed the ePHI of 557 individuals to its former employee and to the web-based scheduling calendar vendor without a HIPAA required business associate agreement in place. Under the two-year corrective action plan, PSMC has agreed to update its security management and business associate agreement, policies and procedures, and train its workforce members regarding the same. (HHS.gov)

Litigation

  • A grand jury returned an indictment on Monday charging three men, including two physicians, with violations of the federal anti-kickback statute as well as conspiring to commit health care fraud, announced U.S. Attorney Trent Shores. The criminal indictment alleges that since November 2012, Christopher Parks and Dr. Gary Lee, both of Tulsa, OK engaged in a conspiracy to unlawfully pay kickbacks and bribes to physicians in order to induce the physicians to write compounding prescriptions to pharmacies with whom the two were affiliated, including OK Compounding LLC in Skiatook, One Stop RX LLC in Tulsa and NBJ Pharmacy LLC and Airport McKay Pharmacy, both in Houston. The defendants then allegedly submitted large claims for payment to federal health care programs and private insurers and divided the profits. (Justice.gov)

 

  • Hospice care provider SouthernCare Inc will pay $5.86 million to resolve claims it submitted claims for payment to Medicare for services that were unnecessary or not properly documented, the U.S. Justice Department said on Thursday. The settlement with the Atlanta-based company will resolve allegations first raised in two separate whistleblower lawsuits filed in 2013 in federal court in Philadelphia by former SouthernCare employees. (Reuters.com)

 

  • United States Attorney William M. McSwain announced Tuesday that Coordinated Health Holding Company, LLC and its founder, principal owner, and Chief Executive Officer, Emil DiIorio, M.D., agreed to settle allegations under the False Claims Act that they submitted false claims to Medicare and other federal health care programs for orthopedic surgeries. Coordinated Health agreed to pay $11.25 million and DiIorio agreed personally to pay $1.25 million, for total settlement of $12.5 million. Coordinated Health is a for-profit hospital and health system based in the Lehigh Valley region of Pennsylvania. Dr. DiIorio is a board-certified orthopedic surgeon. The government alleges that from 2007 through mid-2014, Coordinated Health routinely exploited Modifier 59 to improperly unbundle orthopedic surgery claims, including for many total joint replacement and arthroscopic surgeries.  As a consequence, federal healthcare payers, including Medicare and Medicaid, overpaid Coordinated Health by millions of dollars. The government further alleges that Dr. DiIorio should have stopped the illegal unbundling. Instead, beginning in April of 2009, Dr. DiIorio changed how he wrote operative reports so that Coordinated Health billers could maximize improperly unbundled reimbursements for his knee, hip and shoulder surgeries using Modifier 59. (Justice.gov)

 

  • Aurora Health Care, Inc. has agreed to pay $12 million to the United States and State of Wisconsin to settle allegations that Aurora violated the False Claims Act by submitting claims to Medicare and Medicaid in violation of the Stark Law. The United States and State of Wisconsin allege that, during certain periods from 2008 to 2012, Aurora entered into compensation arrangements with two physicians that did not comply with the Stark Law because the compensation arrangements were not commercially reasonable and because the compensation exceeded the fair market value of the physicians’ services, took into account the physicians’ anticipated referrals, and was not for identifiable services. The United States and the State of Wisconsin allege that Aurora nonetheless submitted claims for services ordered by those physicians to Medicare and Medicaid, in violation of the False Claims Act. (Justice.gov)

 

  • A federal appeals court has upheld a ruling that agreements among Blue Cross Blue Shield companies across the nation to carve out markets and limit competition can be reviewed as inherent violations of the Sherman Anti-Trust Act. In a one-page memorandum issued Wednesday, the 11th U.S. Circuit Court of Appeals sided with U.S. District Judge David R. Proctor, who last April ruled that the healthcare consumers who filed the suit against the Blue Cross Blue Shield companies "have presented evidence of an aggregation of competitive restraints…which, considered together, constitute a per se violation of the Sherman Act." The plaintiffs, who include a class of BCBS customers, allege that the 36 Blue Cross Blue Shield companies have entered non-compete pacts that allocates the markets in which they sell health insurance and caps the amount of unbranded health insurance they offer. The suit, filed nearly six years ago, claims that the pact artificially inflates premiums and decreased consumer choice for health insurance. (HealthLeadersMedia.com

 

  • Kentucky appeals court today upheld a judge’s ruling ordering the release of secret records about Purdue Pharma’s marketing of the powerful prescription opioid OxyContin, which has been blamed for helping to seed today’s opioid addiction epidemic. The records under seal include a deposition of Richard Sackler, a former president of Purdue and a member of the family that founded and controls the privately held Connecticut company. Other records include marketing strategies and internal emails about them; documents concerning internal analyses of clinical trials; settlement communications from an earlier criminal case regarding the marketing of OxyContin; and information regarding how sales representatives marketed the drug. (STATnews.com)

Research

  • The Government Accountability Office released a new report on "Payments for Certain Long-Term Care Hospitals that Specialize in Spinal Cord Treatment." The 21st Century Cures Act included a provision for GAO to examine certain issues pertaining to LTCHs. This report examines (1) the health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; (2) how Medicare LTCH payment polices could affect the two qualifying hospitals; and (3) how the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions. GAO analyzed the most recently available Medicare claims and other data for the two qualifying hospitals and other facilities that treat patients with spinal cord injuries. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others. (GAO.gov)

 

  • The Government Accountability Office released a new report on "State and Local Governments’ Fiscal Outlook 2018 Update." This report updates GAO’s state and local fiscal model to simulate the fiscal outlook for the state and local government sector. This includes identifying the components of state and local expenditures likely to contribute to the sector’s fiscal pressures. In addition, this report identifies considerations related to federal policy and other factors that could contribute to uncertainties in the state and local government sector’s long-term fiscal outlook. Our model also suggests health care costs will largely drive the spending increases—in particular, Medicaid spending and spending on health benefits for state and local government employees and retirees. GAO’s model uses the Bureau of Economic Analysis’s National Income and Product Accounts as the primary data source and presents the results in the aggregate for the state and local sector as a whole. (GAO.gov)

 

 

 

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