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The Weekly Scan

Last Updated: 1:00 PM EST


  • Skyline Urology has agreed to pay the United States $1.85 million to resolve allegations that it violated the False Claims Act by submitting improper claims to the Medicare program for evaluation and management services, the Department of Justice announced Monday. Between Jan. 1, 2013, and Dec. 31, 2016, Skyline Urology allegedly submitted false claims to the Medicare program for evaluation and management (E&M) services that were not allowable under Medicare. Medicare generally prohibits healthcare providers from separately billing for E&M services provided on the same day as another medical procedure, unless the E&M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the medical procedure. If an E&M service satisfies these criteria, the provider can use a billing code known as “Modifier 25” to bill for the significant and separately identifiable E&M services. In this case, the government alleged that Skyline Urology used Modifier 25 to improperly unbundle routine E&M services that were not separately billable from other procedures performed on the same day, and, as a result, improperly claimed compensation from Medicare for certain urological services. (Justice.gov)

  • On Wednesday, Tennessee-based Vanguard Healthcare LLC, and related Vanguard companies agreed to pay more than $18 million in allowed claims to resolve a lawsuit brought by the United States and the State of Tennessee against them for billing the Medicare and Medicaid programs for grossly substandard nursing home services. Vanguard Healthcare and several related Vanguard companies that have reorganized in bankruptcy agreed to pay more than $5.1 million towards the settlement, and two Vanguard entities that are liquidating in bankruptcy have agreed to $13.5 million in allowed claims in bankruptcy. The settlement agreement also resolves claims brought by the United States against Vanguard’s majority owner and CEO, William Orand, and Vanguard’s former director of operations, Mark Miller, who agree to pay $250,000 as part of this settlement. In particular, the United States and Tennessee alleged that the five Vanguard nursing facilities failed to administer medications as prescribed; failed to provide standard infection control, resulting in urinary tract infections and wound infections; failed to provide wound care as ordered; failed to take prophylactic measures to prevent pressure ulcers, such as turning and repositioning; used unnecessary physical restraints on residents; and failed to meet basic nutrition and hygiene requirements of residents. The lawsuit further alleged that the defendants were responsible for the submission of hundreds of pre-admission forms by these facilities to TennCare, Tennessee’s Medicaid Program, which contained forged nurse or physician signatures. (Justice.gov)

  • A home health services company owner and a co-conspirator, both Miami, Florida residents, were sentenced to prison on Wednesday in the Southern District of Florida for their roles in a $8.6 million health care fraud scheme. Alexander Ros Lazo, the owner of T.L.C. Health Services of Miami, was sentenced to serve 87 months in prison. Misleady Ibarra, who performed home health therapy services without a license, was sentenced to serve 24 months in prison. Judge Jordan also ordered Ros Lazo to pay $8,603,859 in restitution and to forfeit the same amount, and Ibarra to pay restitution in an amount to be determined. Ibarra and Ros Lazo pleaded guilty in December 2018 to one count of conspiracy to commit health care fraud. Both defendants were charged in an indictment returned on June 21, 2018. As part of his guilty plea, Ros Lazo admitted that he paid kickbacks and bribes to his co-conspirators in exchange for home health services prescriptions and the referral of Medicare beneficiaries to T.L.C. Health Services. He further admitted that he and Ibarra agreed with their co-conspirators to commit health care fraud by billing Medicare for physical therapy services performed by Ibarra on behalf of licensed therapists despite knowing that she was not licensed to render those services to the Medicare beneficiaries. Ros Lazo admitted that as a result of the fraudulent claims, Medicare paid $8.6 million in benefits that it otherwise would not have. (Justice.gov)


  • The Senate Finance Committee held a hearing on Tuesday titled "Drug Pricing in America: A Prescription for Change, Part II." The hearing including testimonies from executives at AbbVie, Inc., AstraZeneca, Bristol-Myers Squibb Co., Johnson & Johnson, Merck & Co., Inc., Pfizer, and Sanofi. In his opening remarks, Senator Chuck Grassley of Iowa declared: "One of the first things we need to talk about is list price. Secretary Azar has said that pharmaceutical companies believe that the list price is meaningless. In fact, some of your testimony today will echo that. However: For a patient taking a drug that has no competition, the list price is meaningful. For seniors on Part D who are paying co-insurance as a percentage of list price, the list price is meaningful. For people who have high deductible plans and pay thousands of dollars towards list price, the list price is meaningful. For pharmacy benefit managers, providing drugs with a high list price can be more attractive than providing a less expensive drug. Therefore, for taxpayers, the list price is meaningful. We’ve all seen the finger pointing. Every link in the supply chain has gotten skilled at that. But, like most Americans, I’m sick and tired of the blame game. It’s time for solutions." (Finance.Senate.gov)

  • On Thursday, Representatives Debbie Dingell, Pramila Jayapal, other members of Congress and advocates introduced the Medicare For All Act of 2019. Rep. Jayapal commented: “Today in America, 30 million people are uninsured. 40 million are underinsured. We have the most expensive healthcare system in the world and yet our outcomes are the worst of all industrialized countries. I and the more than 100 co-sponsors of this bill refuse to allow this to continue. It’s time to put people’s health over profit. Our bill will cover everyone. Not just those who are fortunate enough to have employer-sponsored insurance. Not just children. Not just seniors. Not just those who are healthy. Everyone. Because healthcare is a human right. We will need every single person in the country to help us, to stand with us, to organize and to fight for this. Because the industry lobby is going to pour hundreds of millions of dollars into killing this bill, saying it costs too much, scaring you into thinking you’re giving up something, pitting the healthy against the sick and the young against the old. It’s time to ensure that healthcare is a right and not a privilege, guaranteed to every single person in our country. It is time for Medicare for All.” (Jayapal.House.gov)

  • Also on Thursday, U.S. Sen. Mark R. Warner (D-VA), a member of the Senate Finance Committee, and Sen. Doug Jones (D-AL) were joined by Sen. Tim Kaine (D-VA) and six other Senators in introducing legislation that would allow states that expanded Medicaid after 2014 or expand in the years ahead to receive the same full federal matching funds as states that expanded earlier under the terms of the Affordable Care Act. The States Achieve Medicaid Expansion (SAME) Act of 2019 is also co-sponsored by Sens. Tammy Baldwin (D-WI), Tom Carper (D-DE), Chris Coons (D-DE), Angus King (I-ME), Gary Peters (D-MI), and Debbie Stabenow (D-MI). The bill would ensure that the twelve states that chose to expand Medicaid after January 1, 2014 are eligible for the same level of federal matching funds as those that expanded earlier under the terms of the Affordable Care Act. These states are Alaska, Idaho, Indiana, Louisiana, Maine, Michigan, Montana, Nebraska, New Hampshire, Pennsylvania, Utah and Virginia, where Medicaid expansion went into effect on January 1, 2019, finally allowing more than 400,000 Virginians to access low-cost or no-cost healthcare coverage under Medicaid. The bill would also provide a financial incentive to the 14 states that have not yet expanded Medicaid to do so. (Kaine.Senate.gov)

Medicare & Medicaid

  • On Thursday, the CMS updated hospital performance data on the Hospital Compare website and on data.medicare.gov to empower patients, families, and stakeholders with important information they need to compare hospitals and make informed healthcare decisions. This data includes specific measures of hospitals’ quality of care, many of which are updated quarterly, and the Overall Hospital Star Ratings, which were last updated in December 2017. The data are collected through CMS’s Hospital Quality Initiative programs. Also on Thursday, CMS posted potential changes to the Hospital Star Ratings for public comment. These changes under consideration, intended to respond to stakeholder feedback, seek to enhance the Star Ratings methodology by making hospital comparisons more precise and consistent, and by allowing more direct, “like-to-like” comparisons. One potential change, recommended by some hospitals, would place hospitals with similar characteristics into “peer groups” allowing, for example, small hospitals to be compared to other small hospitals instead of all hospitals. CMS developed these potential changes with feedback from hospitals and other stakeholders through a series of listening sessions and by considering input from a technical expert panel. The agency looks forward to public comments on the potential changes, due March 29, 2019. (CMS.gov)


  • The Government Accountability Office (GAO) released a new report on Thursday titled "Veterans Health Administration: Greater Focus on Credentialing Needed to Prevent Disqualified Providers from Delivering Patient Care." VHA provides health services to almost 9 million veterans at medical facilities nationwide. Through the credentialing process, VHA facilities determine whether providers have the appropriate professional qualifications to provide care. The NPDB is one information source VHA uses to determine whether providers have been disciplined by a state licensing board or a health-care facility. Such discipline results in “adverse actions,” that may disqualify providers from practicing at VHA. GAO was asked to review how allegations of provider misconduct are resolved. GAO examined (1) how officials at VHA facilities responded to adverse-action information received through NPDB, (2) how VHA facilities adhered to polices regarding providers with adverse actions, and (3) steps VHA has recently taken to ensure that providers meet licensure requirements. GAO is making seven recommendations, including that VHA ensure that facility officials responsible for credentialing and hiring receive periodic mandatory training, and periodically review providers who have an adverse action reported in NPDB. (GAO.gov)

#Research #Litigation #Legislation #Medicaid #Medicare


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