Literature Review

DOJ slaps $20M opioid prescription penalty on OptumRx Fierce Healthcare; by Noah Tong; 7/2/24 OptumRx will pay $20 million to resolve claims the company violated the Controlled Substances Act by improperly filling certain opioid prescriptions, the Department of Justice recently announced. The agency claims OptumRx did not fill prescriptions correctly for "trinity prescriptions" like benzodiazepines and other muscle relaxants from April 2013 to April 2015. These prescriptions, which are addictive, may not have been “intended for legitimate medical use” and carry “significant risk of harm,” according to a news release. “Pharmacies providing opioids and other controlled substances have a duty under the Controlled Substances Act to ensure that they fill prescriptions only for legitimate medical purposes,” said Principal Deputy Attorney General Brian Boynton, head of the Justice Department’s Civil Division, in a statement. “The department will continue to work with its law enforcement partners to ensure that pharmacies do not contribute to the opioid addiction crisis.”

Lawmakers say CMS should ban Medicare Advantage’s use of AI to deny care McKnights Long-Term Care News; by Josh Henreckson; 6/26/24 The Centers for Medicare & Medicaid Services should consider banning artificial intelligence from being used to deny Medicare Advantage coverage pending a “systematic review,” a group of 49 congressional leaders is urging. ...  Skilled nursing providers have been sounding the alarm for years on Medicare Advantage coverage access, especially when informed by AI and other algorithms. Sector leaders have frequently noted that these methods can deny or prematurely end coverage for patients who need it to afford necessary long-term care. Providers and consumer advocates both spoke out in favor of the lawmakers’ letter this week. “LeadingAge’s nonprofit and mission driven members … have firsthand experience of Medicare Advantage (MA) plans’ inappropriate use of prior authorization to deny, shorten and limit MA enrollees’ access to medically necessary Medicare benefits,” wrote Katie Smith Sloan, president and CEO of LeadingAge. ... “Implementation by [the] Centers for Medicare and Medicaid Services (CMS), which we fully support, would ensure MA plans fulfill their obligation to provide enrollees equitable access to Medicare services.”

National Health Care Fraud Enforcement Action results in 193 defendants charged and over $2.75 billion in false claims United States Attorney's Office - Western District of Virginia, Charlottesville, VA; 6/27/24 The Justice Department today announced the 2024 National Health Care Fraud Enforcement Action, which resulted in criminal charges against 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals in 32 federal districts across the United States, for their alleged participation in various health care fraud schemes involving approximately $2.75 billion in intended losses and $1.6 billion in actual losses. In connection with the coordinated nationwide law enforcement action, and together with federal and state law enforcement partners, the government seized over $231 million in cash, luxury vehicles, gold, and other assets. 

‘Lot of work to be done’: What home health leaders expect from payment rulemaking in 2024Home Health Care News; by Joyce Famakinwa; 6/24/24 In recent years, home health care has faced relentless cuts from the Centers for Medicare & Medicaid Services (CMS). It has plagued the industry, but providers and advocates alike are still hopeful a light at the end of the tunnel is ahead. ... Home Health Care News recently caught up with PQHH CEO Joanne Cunningham and David Totaro, the president and executive director of Hearts for Home Care. ... [Cunningham said,] "I anticipate that what we will see, given CMS’s posture and prior rulemaking cycles, is the continuation of the policy that will put in place permanent cuts to the Medicare home health program. We’re bracing ourselves for an additional sizable permanent cut. We don’t know exactly what CMS has planned for the temporary cuts, otherwise known as the clawback cuts. We will certainly see, at a minimum, CMS identify what their new projected value of the temporary cuts are. ...

Chicago laboratory owner charged with defrauding Medicare in $60 million COVID-19 test kit scheme JD Supra; by Randall Brater, M.H. Joshua Chiu, Michael Dearington, Rebecca Foreman, Nadia Patel, D. Jacques Smith, Hillary Stemple; 6/17/24 The Chicago-based owner of two laboratories, Zoom Labs Inc. and Western Labs Co., has been charged with health care fraud and money laundering in connection with more than $60 million in Medicare claims for over-the-counter (OTC) COVID-19 test kits, including tests delivered to thousands of deceased beneficiaries. Federal prosecutors began investigating Medicare claims from Syed S. Ahmed’s two laboratories after noticing a “massive spike” in the laboratories’ claims in 2023, which coincided with Ahmed assuming control of Zoom [Labs]. ... Ahmed is charged with health care fraud under 18 U.S.C. § 1347 and money laundering under 18 U.S.C. §§ 1956 and 1957. 

CMS recalculates Medicare Advantage star ratings Becker's Payer Issues; by Rylee Wilson; 6/13/24CMS has recalculated Medicare Advantage plans' star ratings after insurers challenging the agency's methodology were handed court victories. In a memo sent to MA plans on June 13, the agency said it would recalculate plans' star ratings for 2024 without eliminating extreme outliers.  

Care provider to pay $14.9M over false claims involving assisted living communitiesMcKnight's Senior Living; Kimberly Bonvissuto; 6/10/24A chronic disease management provider will have to shell out $14.9 million over allegations related to false claims involving assisted living communities, memory care communities and group homes. Bluestone Physician Services of Florida LLC, Bluestone Physician Services PA of Minnesota and Bluestone National LLC of Wisconsin agreed to a $14.9 million settlement with the Justice Department. The federal government alleged that Bluestone knowingly submitted false claims to Medicare, Medicaid and TRICARE — the healthcare program for active duty service members and their families — for certain evaluation and management codes for services related to chronic care management of assisted living residents. The settlement agreement resolves allegations that Bluestone submitted “inflated” claims between Jan. 1, 2015, and Dec. 31, 2019, that did not support the level of service provided. The federal government will receive $13.8 million from the settlement, with more than $1 million going to the states of Florida and Minnesota.

U.S. Rep. Beth Van Duyne: Crack down on hospice fraud Hospice News; by Jim Parker; 6/12/24 Rep. Beth Van Duyne, (R-Texas) has emerged as one of Washington’s most vocal advocates for hospice providers in Congress. ... Van Duyne was among a group of lawmakers that wrote to CMS Administrator Chiquita Brooks LaSure last month requesting updates on the agency’s battles against fraudulent providers, as well as a U.S. Government Accountability Office (GAO) report on quality issues in the hospice space. Hospice News spoke with Rep. Van Duyne in Washington D.C. on congressional efforts to root out fraud and where they should go next. 

Five arrested over 'sham hospices' alleged to bilk Medicare for over $15 million Los Angeles Times; by Emily Alpert Reyes; 6/8/24 Angeles over an alleged scheme to bilk the Medicare program of more than $15 million. The U.S. Department of Justice said three of the San Fernando Valley residents who were arrested — Petros Fichidzhyan, also known as Peter; Juan Carlos Esparza; and Karpis Srapyan, also known as Tony Levy — were accused of running "sham hospice companies" and turning in fraudulent claims to Medicare for hospice services. ... As part of the alleged scheme, the three defendants misappropriated the identifying information of doctors to claim those physicians had deemed hospice services necessary for patients, federal prosecutors said. They also allegedly used the names and Social Security numbers of Russian and Ukrainian citizens who had left the U.S. to open bank accounts and sign leases, indicating that the "impersonated identities" were the owners of the hospice companies that they in fact controlled, according to the federal indictment. 

How fraudulent hospices evade regulators Hospice News; by Jim Parker; 6/5/24A slew of fraudulent hospices in California are dodging consequences by shuffling patients around between provider numbers. That’s according to multiple sources who spoke with Hospice News, expressing their concerns about patterns of fraud continuing even as government regulators crack down on the sector. Since 2021, numerous media and government reports have emerged of unethical or illegal practices among hundreds of newly licensed hospices, particularly among new companies popping up in California, Texas, Nevada and Arizona. Despite the best efforts of regulators and law enforcement, hospice leaders are concerned that many bad actors are slipping through the cracks. 

Hospice groups to CMS: Don’t rush CAHPS changes Hospice News; by Jim Parker; 6/3/24Hospice industry organizations have voiced support for proposed updates to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, but raised questions on the implementation timeline. ... One key concern about the timeline is the need for vendors to develop updated electronic medical record (EMR) systems as well as methods of collecting the data, according to Katy Barnett, director of home care and hospice operations for LeadingAge. ... The proposed changes include:

SCAN wins Medicare Advantage star ratings lawsuit against CMSModern Healthcare; by Nona Tepper; 6/4/24SCAN Health Plan has prevailed in a widely watched federal lawsuit brought last year against the Centers for Medicare and Medicaid Services that alleged regulators did not appropriately calculate the insurer's Medicare Advantage star rating. The decision could have industrywide implications for the star ratings program if regulators decide to recalculate all carriers’ star scores for the 2024 plan year. The ruling could also affect several pending cases filed by other insurers against CMS. It also could be appealed.

Joel Mekler - Medicare Moments: Watch out for these latest scams New Castle News; by Joel Mekler; 6/3/24 ... Across the country, many unscrupulous hospice providers are recruiting and enrolling nonterminally ill patients for end-of-life care they do not need and then billing Medicare for services and items they may never receive. They trick beneficiaries into signing up for hospice by offering freebies, such as additional groceries, nurse visits, durable medical equipment, bus coupons, and more once they enroll. They also make false claims, such as saying “Medicare now covers cooking and cleaning services”. Or they tell beneficiaries they qualify due to age, saying “You’re now old enough to qualify for hospice!” Another tactic is giving money, with some recruiters telling beneficiaries, “You can earn $400/month if you agree to enroll in our program.” ... Tips [to consumers] to avoid hospice fraud: