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The Weekly Scan

Last Updated: 1:00 PM EST

Medicare & Medicaid

  • Utah Gov. Gary Herbert on Monday signed legislation adopting a limited expansion of the state’s Medicaid program, defying voters who in November approved the full Obamacare program through the ballot. Under the new GOP-written plan, Utah will ask the Trump administration for permission to implement unprecedented restrictions on the health coverage program for the poor, while insuring about 60,000 fewer people than the Obamacare expansion would have and initially costing the state tens of millions of dollars more. In a statement, Herbert said: “SB 96 balances Utah’s sense of compassion and frugality. It provides quality coverage to the same population covered by Proposition 3 in a meaningful, humane and sustainable way. It is now time to set aside differences and move forward to get those in greatest need enrolled on Medicaid and on the federal health care exchanges.” (Governor.Utah.gov, Politico.com)

  • On Monday, HHS proposed new rules to support seamless and secure access, exchange, and use of electronic health information. The rules, issued by CMS and the Office of the National Coordinator for Health Information Technology (ONC), would increase choice and competition while fostering innovation that promotes patient access to and control over their health information. The proposed ONC rule would require that patient electronic access to this electronic health information (EHI) be made available at no cost. CMS’ proposed changes to the healthcare delivery system support the MyHealthEData initiative and would increase the seamless flow of health information, reduce burden on patients and providers, and foster innovation by unleashing data for researchers and innovators. For the first time, CMS is now proposing requirements that Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and Qualified Health Plans in the Federally-facilitated Exchanges must provide enrollees with immediate electronic access to medical claims and other health information electronically by 2020. In support of patient-centered healthcare, CMS would also require these health care providers and plans to implement open data sharing technologies to support transitions of care as patients move between these plan types. (HHS.gov)

  • On Thursday, the U.S. Department of Health and Human Services (HHS), Center for Medicare and Medicaid Innovation (Innovation Center) announced a new payment model for emergency ambulance services that aims to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs. The new model, the Emergency Triage, Treat and Transport (ET3) model, will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 model will have a five-year performance period, with an anticipated start date in early 2020. (HHS.gov)


  • The Justice Department announced Monday that GenomeDx Biosciences Corp. has agreed to pay $1.99 million to resolve allegations that it violated the False Claims Act, 31 U.S.C. §§ 3729 et seq., by submitting claims to Medicare for the Decipher® post-operative genetic test for prostate cancer patients. GenomeDx is a genetic testing laboratory headquartered in Vancouver, British Columbia, with operations based in San Diego. The United States alleged that GenomeDx knowingly submitted claims for the Decipher test to Medicare between September 2015 and June 2017 that were not medically reasonable and necessary because the prostate cancer patients did not have risk factors necessitating the test, including pathological stage T2 disease with a positive surgical margin, pathological stage T3 disease or rising Prostate-Specific Antigen (PSA”) levels after an initial PSA nadir. (Justice.gov)

  • A Florida health care executive used bribery, kickbacks and false paperwork in a $1 billion effort to fleece Medicare and Medicaid, one of the biggest such cases in U.S. history, a federal prosecutor told jurors Tuesday. The opening statements kicked off a trial expected to last about eight weeks. Philip Esformes faces decades in prison if convicted because of the scope of the alleged fraud committed between 2006 and 2016. Assistant U.S. Attorney Elizabeth Young told the jury the fraud involved four steps: bribing doctors to refer patients to Esformes' facilities, moving them to other facilities when their Medicare eligibility at the first place expired, selling access to patients to others so they could also defraud the government programs, and then starting the process again. Prosecutors say the Esformes network and co-conspirators falsely billed Medicare alone for $1 billion during the scheme, of which about $500 million was paid. (TampaBay.com)

  • Federal prosecutors alleged in court on Wednesday that a company at the center of a criminal investigation stemming from the nation's opioid epidemic used a music video to motivate employees to push sales of a highly addictive fentanyl spray. Former executives and managers of Insys Therapeutics are accused of bribing doctors to prescribe the drug. Those former Insys executives and managers are charged with conspiring with one another to use bribes and kickbacks for doctors who wrote large numbers of prescriptions. The video shown in court Wednesday is just one piece of mounting evidence in the case. Prosecutors said a five-minute rap video debuted at an Insys sales conference in 2015. In it, two young salesmen promote the powerful fentanyl spray Subsys. The message: encourage Insys sales representatives to push doctors to increase the strength of Subsys prescriptions until a patient reaches the adequate dosage. It's a process known as "titration." (CBSNews.com)

  • U.S. Attorney William M. McSwain announced Thursday that Prime Healthcare Services, Inc. and Prime’s Founder and CEO, Dr. Prem Reddy, have agreed to pay the United States $1.25 million to settle allegations that two Prime hospitals in Pennsylvania – Roxborough Memorial Hospital in Philadelphia and Lower Bucks Hospital in Bristol – knowingly submitted false claims to Medicare by engaging in the following conduct: (1) admitting patients to the hospital for overnight stays who required only less costly, outpatient care and (2) billing for more expensive patient diagnoses than the patients had (the latter practice known as “up-coding”). The Settlement resolves allegations that Prime submitted or caused the submission of fraudulent claims to Medicare. Specifically, from the date that Prime acquired Roxborough and Lower Bucks through September 30, 2013, under Prime management, Roxborough and Lower Bucks hospitals admitted emergency room Medicare patients for costly and medically unnecessary one- and two-day overnight hospital stays, instead of treating the patients in less costly outpatient service or keeping them under observation. In addition, from the dates of acquisition through December 31, 2014, the hospitals upcoded inpatient diagnoses (i.e., billed Medicare for more serious medical conditions than the patients actually had) to increase Medicare payments. (Justice.gov)

Private Sector

  • Johnson & Johnson, announced Wednesday that its subsidiary Ethicon, Inc., entered into a definitive agreement to acquire Auris Health, Inc. for approximately $3.4 billion in cash. Additional contingent payments of up to $2.35 billion, in the aggregate, may be payable upon reaching certain predetermined milestones. Auris Health is a privately held developer of robotic technologies, initially focused in lung cancer, with an FDA-cleared platform currently used in bronchoscopic diagnostic and therapeutic procedures. This acquisition will accelerate Johnson & Johnson’s entry into robotics with potential for growth and expansion into other interventional applications. “In this new era of health care, we’re aiming to simplify surgery, drive efficiency, reduce complications and improve outcomes for patients, ultimately making surgery safer,” said Ashley McEvoy, Executive Vice President, Worldwide Chairman, Medical Devices, Johnson & Johnson. (AurisHealth.com)

#PrivateSector #Litigation #Medicaid #Medicare


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