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The Weekly Scan

Last Updated: 1:00 PM EST


  • Announced on Tuesday, one of the largest health care fraud schemes investigated by the FBI and the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) and prosecuted by the Department of Justice resulted in charges against 24 defendants, including the CEOs, COOs and others associated with five telemedicine companies, the owners of dozens of durable medical equipment (DME) companies and three licensed medical professionals, for their alleged participation in health care fraud schemes involving more than $1.2 billion in loss, as well as the execution of over 80 search warrants in 17 federal districts. In addition, the Center for Medicare Services, Center for Program Integrity (CMS/CPI) announced that it took adverse administrative action against 130 DME companies that had submitted over $1.7 billion in claims and were paid over $900 million. The charges target an alleged scheme involving the payment of illegal kickbacks and bribes by DME companies in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for back, shoulder, wrist and knee braces that are medically unnecessary. (Justice.gov)


  • Senator Bernie Sanders and 14 of his Democratic colleagues introduced the Medicare for All Act of 2019 on Wednesday to "guarantee health care to every American as a right, not a privilege." A press release from the Senator's office explains: "The Medicare for All Act of 2019 would ensure that Americans could go to the doctor of their choice and get the care they need, when they need it, without going into debt. It would significantly lower the price of prescription drugs by empowering the federal government to negotiate with pharmaceutical corporations. And it would expand coverage to include home and community based long-term care services, ensuring people with disabilities can receive the care they need to stay in their homes and remain part of their communities. Under this bill, Americans will benefit from the freedom and security that comes with finally separating health insurance from employment. As is the case in every other major country, employers would be free to focus on running their businesses rather than spending time, energy and money trying to provide health insurance to their employees." (Sanders.Senate.gov: Press Release, Full Text of Act)

  • Two senators are asking the Office of Inspector General (OIG) to investigate pharmacy benefit managers' business practices when it comes to controversial spread pricing models. Sens. Chuck Grassley, R-Iowa, and Ron Wyden, D-Ore., the top Republican and Democrat on the Finance Committee, wrote in a letter to the Department of Health and Human Services' OIG that an "increasing number of reports" raise concerns about how PBMs are operating. Spread pricing, in which a PBM charges an insurer more for a drug than a pharmacy paid and profits off of the difference, has come under fire in several states. Ohio, for instance, ended contracts with the PBMs in its Medicaid program after a state report found they earned $224 million between April 2017 and March 2018 through spread pricing. Other states, including Pennsylvania and New York, have also sounded the alarm about the practice. (FierceHealthcare.com)

Medicare & Medicaid

  • On Tuesday, the CMS proposed to update its national coverage policy for Ambulatory Blood Pressure Monitoring (ABPM). ABPM is a non-invasive diagnostic test that uses a device to track blood pressure over 24-hour cycles. Ambulatory monitoring allows blood pressure to be measured over entire days rather than at a single moment in time. ABPM may measure blood pressure more accurately and lead to the diagnosis of high blood pressure (hypertension) in patients who would not otherwise have been identified as having the condition. “With the prevalence of chronic diseases – including high blood pressure – increasing among Medicare beneficiaries, it is critical that our agency closely monitor the evidence for interventions that could improve health outcomes for patients with these conditions,” said CMS Administrator Seema Verma. “Today’s proposal to expand coverage of Ambulatory Blood Pressure Monitoring is supported by many years of evidence and would help ensure that beneficiaries have their blood pressure measured accurately, so they can receive the care that is best for them.” (CMS.gov)

  • The Trump administration on Wednesday appealed recent rulings in a closely watched case involving health care for the poor, after a federal judge blocked work requirements for some low-income people on Medicaid. The rulings last month by Judge James Boasberg in Washington D.C. blocked requirements for “able bodied” adults in Arkansas and Kentucky under which Medicaid recipients either had to work, study, volunteer or perform other “community engagement” activities. The Justice Department filed notice appealing to the U.S. Court of Appeals for the District of Columbia Circuit. Arkansas also appealed. The Arkansas requirements were already in effect, while in Kentucky they’re a top priority for Republican Gov. Matt Bevin. The work requirements apply to hundreds of thousands of low-income people in both states who gained health insurance under the Affordable Care Act’s Medicaid expansion. (APNews.com)

  • The Florida House of Representatives approved a bill Thursday that would allow ridesharing companies like Uber and Lyft to provide non-emergency medical transportation for Medicaid patients. The bill (HB 411) would allow companies, through managed care providers, to take patients to and from doctors appointments that don’t require an ambulance. Uber is already transporting passengers for medical appointments in the private sector through its platform, Uber Health. The company contracts with Bay Care to provide services. Under the program, instead of hailing a ride directly through an app or a user’s phone, patients would schedule rides through their managed care provider. That patient would then get a text message containing information about the make and model of the car picking them up, the driver’s name and the estimated wait and travel time for the ride. Supporters say it’s a necessary tool for Medicaid recipients who often arrive late or miss appointments through traditional non-emergency transportation options. (FloridaPolitics.com)

  • According to a new analysis in Health Affairs, physicians in states where Medicaid rates are closer to Medicare reimbursement rates accept new Medicaid patients at a higher rate. On average, Medicaid paid 72% of what Medicare reimbursed in 2016. There were no significant differences in provider acceptance rates of new patients between states that expanded their Medicaid programs and those that did not, according to the report, which examined data from the Medicaid and Children's Health Insurance Program Payment and Access Commission. One exception was for OB/GYNs — 90% accepted new patients in non-expansion states compared to 74% in expansion states. The review also found no difference in acceptance rates based on a state's Medicaid managed care offerings, which the authors said was similar to previous studies. (HealthcareDive.com)

#Medicaid #Medicare #Legislation #Litigation


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