Monday Morning Medicaid Must Reads: July 16th, 2018

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


Article 1:  

More Than 600 Charged In Historic Opioid Fraud Takedown, Beth Leipholtz, The Fix, 7/10/2018

Clay’s summary: The national fraud sweeps get cooler and cooler to watch each year. I think they should wear go pros next time so we can watch in real time as they kick in doors.

Key Passage from the Article

“This is the most fraud, the most defendants, and the most doctors ever charged in a single operation,” said Attorney General Jeff Sessions.Sessions says the DOJ’s investigation “has stopped or prevented billions of dollars’ worth of fraud.” More than 600 people within 58 federal districts have been charged by the U.S. government for their involvement in “multi-billion-dollar profit-making schemes involving opioid painkillers,” CBS News reported.

On Thursday, June 28, the U.S. Justice Department announced the charges, which have to do with billing government programs like Medicare and Medicaid, as well as private insurers, for prescription medications that have been deemed medically unnecessary. These actions resulted in more than $2 billion in losses, the Justice Department and the Department of Health and Human Services states.

Read it here 

Article 2:   

GAO Confirms It: 340B Hospitals and Contract Pharmacies Profit from Low-Income, Uninsured Patients, Adam J Fein, Drug Channels, July 10, 2018

Clay’s summary: 340B can be an amazing profit center for providers who choose to not pass the savings onto patients.

Key Passage from the Article

The United States Government Accountability Office (GAO) has just issued a must-read report on the 340B Drug Pricing Program: Federal Oversight of Compliance at 340B Contract Pharmacies Needs Improvement.

Some of the report’s most startling revelations confirm our worst fears about how hospitals and pharmacies are abusing the 340B program.

Here are two especially dispiriting findings from the GAO’s analysis:

16 out of 28 hospitals (57%!) did not provide discounted drug prices to low-income, uninsured patients who filled prescriptions at the hospital’s 340B contract pharmacy. Seriously?!?
Many 340B contract pharmacies can earn excessive profit margins of 15% to 20% from brand-name 340B prescriptions. As I have long suspected, large, publicly-traded pharmacies are sharing in the 340B discounts generated for covered entities.
Bottom line: Hospitals and pharmacies are making money from poor people. Are you kidding me?!? For shame!

The 340B program’s apologists will have a hard time rebutting the uncomfortable facts from this GAO report. Calling something a “drug discount program” apparently doesn’t mean that the neediest patients get access to those discounts. Read on, and prepare to be outraged.


Read it here




Article 3:   

CMS suspends $10.4B in risk adjustment payments to insurers, Evan Sweeney, Fierce Healthcare, July 9, 2018

Clay’s summary: Health plans have a pretty big outstanding invoice. A smaller plan in NM is gumming up the works for the big guys with a lawsuit that says ACA calculations for the payments favor bigger plans.

Key Passage from the Article

Citing a March court ruling, the Centers for Medicare & Medicaid Services announced over the weekend that it is placing payments on hold while it resolves the litigation. Insurers on the Affordable Care Act marketplace are owed $10.4 billion in risk adjustment payments for the 2017 benefit year, which were slated to be paid in the fall. “We were disappointed by the court’s recent ruling,” CMS Administrator Seema Verma said in a statement. “As a result of this litigation, billions of dollars in risk adjustment payments and collections are now on hold.”

Verma added that CMS has asked the U.S. District Court for the District of New Mexico to reconsider its ruling and that the agency “hopes for a prompt resolution.”

The case involves New Mexico Health Connections, a consumer operated and oriented plan (CO-OP), which sued the Department of Health and Human Services (HHS) over what the insurer said was a flaw in the calculation that favored larger insurers. Judge James Browning ruled that HHS’ formula was not illegal but should be re-examined.

A separate ruling in Massachusetts in January found HHS acted within its authority in calculating risk adjustment payments. The program was created under the ACA to prevent insurers from risk selection and avoiding sicker enrollees.

Read it here