Monday Morning Medicaid Must Reads: August 13th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 


Article 1:  

165 medical professionals charged in $2B DOJ, HHS healthcare fraud investigation: 5 facts, Rachel Popa, Beckers, July 24, 2018

Clay’s summary: Good highlights list from the recent massive fraud dragnet.

Key Passage from the Article

 The federal government’s largest-ever investigation led by the DOJ and HHS into healthcare fraud in the U.S. stretched across 58 federal districts and included 165 medical professionals, physicians and nurses accused of allegedly profiting from false healthcare billings, according to the DOJ.

Over 600 people were charged in the investigation with committing more than $2 billion in fraud and taxpayer theft. The report details several incidences where physicians and healthcare providers allegedly committed fraud, received kickbacks or fraudulently prescribed medications.

Here are the key facts from the investigation: 1. The investigation focused on fraudulent

Read it here 

Article 2:   

CMS proposes to overhaul Medicare billing standards, pay for telehealth, Virgil Dickson, Modern Healthcare, July 12, 2018

Clay’s summary: 2018 may just be the year telehealth breaks through.

Key Passage from the Article

 In a lengthy proposed rule, the agency said it would pay doctors for their time when they reach out to beneficiaries via telephone or other telecommunications devices to decide whether an office visit or other service is needed. In addition, the CMS also proposed paying for the time it takes physicians to review a video or image sent by a patient seeking care or diagnosis for an ailment.  “This is a big issue for the elderly and disabled population for which transportation can be a barrier to care,” CMS Administrator Seema Verma said. “We’re not intending to replace office visits but rather to augment them and create new access points for patients.”  Most physicians bill Medicare for patient visits under a relatively generic set of codes that distinguish level of complexity and site of care, known as evaluation and management visit codes. 

Read it here




Article 3:   

Drugmakers try evasion, tougher negotiations to fight new U.S. insurer tactic, Michael Erman, Reuters, July 5, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: “Copay accumulator programs”- What will they think of next? My head hurts trying to keep up with the insurance-PBM fights… These are some clever folks, worthy adversaries..

Key Passage from the Article

 In recent years, insurers have tried to guide patients toward less expensive treatments by making them pay a higher portion of a drug’s costs. Drugmakers responded by dramatically raising the financial aid they offer, in the form of “copay assistance” cards – similar to a debit card – that reduce what consumers need to pay when they place their pharmacy order. Express Scripts Holding Co and CVS Health, which manage prescription drug coverage for large U.S. employers, say these payments shield consumers from drug costs, making it easier for manufacturers to raise those prices. Insurers have to make up the difference.

This year, Express Scripts and others introduced a new “copay accumulator” approach for its corporate customers. The programs prevent copay card funds from counting toward a patient’s required out-of-pocket spending before insurance kicks in on expensive specialty drugs, such as arthritis and HIV treatments.

As an example, a patient whose medicine costs $1,000 per month might be required to pay that amount until they reach a deductible of $2,000 set by their insurer. A copay card from the drugmaker would cover most, or all, of those costs for the patient and it would count towards the deductible. When the deductible is reached, the insurance begins to pay.

Read it here