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Following the first approved Medicaid section 1135 waiver for Florida, the Centers for Medicare and Medicaid Services has approved 33 more waiver requests in the last 2 weeks....The waivers are intended to provide the states with relief during the coronavirus disease 2019 pandemic by providing states the flexibility to focus resources on managing the outbreak. Some waivers available under Section 1135 of the Social Security Act include temporary suspension of prior authorization requirements; extension of existing authorizations; modified timeline requirements for state fair hearings and appeals; and relaxed provider enrollment requirements to allow states to quickly enroll out-of-state or other new providers...READ MORE

Lawsuits over Medicaid rebates are a fact of life in pharma, and in one particularly long-running case, Bristol-Myers Squibb stands accused of fiddling with its prices to lower payments. Now, after seven years in litigation, that lawsuit could be nearing an end...Bristol reached an "agreement in principle" in January to settle a 2013 whistleblower lawsuit accusing the company of manipulating the average manufacture price of its drugs in order to underpay Medicaid rebates between 2007 and 2016, according to an SEC filing...READ MORE

CVS Health Corp and its Omnicare unit were sued...by the U.S. government, which accused them of fraudulently billing Medicare and other programs for drugs for older and disabled people without valid prescriptions...The Department of Justice joined whistleblower litigation accusing Omnicare of violating the federal False Claims Act for illegally dispensing drugs to tens of thousands of patients in assisted living facilities, group homes for people with special needs, and other long-term care facilities...According to a civil complaint filed in Manhattan federal court, Omnicare would often assign new numbers to prescriptions after the original prescriptions expired or ran out of refills...The government said this enabled Omnicare to bill Medicare Medicaid, and Tricare...for hundreds of thousands of drugs, under what the company internally called “rollover” prescriptions, from 2010 to 2018...READ MORE

Medicare and Medicaid will cover CAR-T cell therapies...a decision that helps address, but doesn't fully solve, the reimbursement challenges that have hampered uptake of the pricey cancer drugs...One major hang-up is reimbursement. Kymriah costs $475,000 for pediatric and young adult patients with leukemia and both therapies are priced at $373,000 to treat lymphoma in adults...Under regulations published this month, Medicare will reimburse at least 65% of the treatment's cost, or about $242,000, through Part B...That will give hospitals surety they will receive payment for the drug, yet doesn't necessarily make whole the full cost of treating a patient with CAR-T. The cell therapies are also still reimbursed via billing codes for bone marrow and stem cell transplants, rather than using a separate identifier...READ MORE

The Trump administration has issued blanket waivers and new flexibilities to help hospitals and facilities cope with the coronavirus outbreak...“It is vital that federal requirements designed for periods of relative calm do not hinder measures needed in an emergency,” CMS Administrator Seema Verma said in a statement. “The nationwide waivers we are activating today will be a godsend for those on the frontlines of the fight against this new virus.”...Some of the waivers and flexibilities that CMS took on Friday include:

• Waiving requirements that critical access hospitals limit the number of beds to 25 and length of stay to 96 hours;
• Enabling acute care hospitals to house acute care patients in a separate unit;
• Waiving replacement requirements when durable medical equipment gets damaged or unusable. A contractor can waive requirements such as a new physician’s order, face-to-face requirement and other documentation; and
• Allowing long-term care hospitals to exclude patients stays from the 25-day average length requirement if treatment is required in conjunction with the emergency.
• CMS also sought to quickly approve waivers for states and territories for Medicare, Medicaid and the Children’s Health Insurance Program...READ MORE

NACDS is welcoming “the strongest signal yet” by the Centers for Medicare & Medicaid Services that a standardized pharmacy quality program should be created...In a new proposed rule, CMS proposed taking action to increase transparency in Medicare Part D plan sponsors’ pharmacy performance measures, NACDS said in a press release Plan sponsors would have to disclose these measures and CMS would publish them, according to the proposal...The CMS rule also recommends principles to guide pharmacy performance measures, urges the industry to work together toward appropriate measures, and indicates the possibility that CMS may incent plans to use appropriate quality measures, NACDS said...READ MORE

Fourteen doctors and other medical professionals were among those charged in fraud schemes that totaled $258 million in California, Oregon and Arizona...Charges were brought...against 34 people for alleged Medicare and Medicaid fraud…The charges targeted schemes billing Medicare and Medicaid for services, testing, and prescriptions that were not medically necessary or not actually provided to beneficiaries...READ MORE

Amid efforts to close a $1.6 billion opioid settlement, Mallinckrodt has fought tooth and nail to escape a massive Medicaid rebate bill for its controversial H.P. Acthar Gel. Instead of ceding ground, the U.S. government opted to take the fight right back to Mallinckrodt––and it could create even more trouble for the embattled drugmaker...The federal government has joined a False Claims Act whistleblower suit filed in Boston accusing Mallinckrodt of underpaying Medicaid rebates for Acthar by "hundreds of millions of dollars,"...READ MORE

Leapfrog’s highest “A” rated hospitals for 2019 has remained unchanged from last year. These are Henderson Hospital, Mountainview Hospital, Northern Nevada Medical Center, Renown South Meadows Medical Center, and St. Mary's Regional Medical Center of Reno.

The Leapfrog Group hospital grading system is based on Centers for Medicare & Medicaid Services data collection and represents a single metric that evaluates a hospital’s overall safety performance. The nonprofit is dedicated to transparency and has created the Leapfrog Hospital Safety Grade as a quality standard for comparing health care institutions.

The “B” team consists of North Vista Hospital, Valley Hospital Medical Center, St. Rose Dominican Hospitals - Siena Campus, St. Rose Dominican Hospitals - San Martin Campus, and Renown Regional Medical Center.

The good news is two of these hospitals have shown a marked safety improvement by moving up from a “C” rating to a “B” rating; these are: Valley Hospital Medical Center, and Renown Regional Medical Center.

These hospitals are to be applauded for consistently maintaining high standards and striving to improve patient care.

The bad news is the University Medical Center of Southern Nevada continues to struggle with its’ “D” rating.

By Chase

12.30.2019

...Healthcare for Missouri’s efforts to put the issue of Medicaid expansion on the 2020 ballot has raised more than $1.3 million to start the campaign…The campaign is drawing support from those in the healthcare community...Some within the healthcare community in Nevada are also eager to get the question to Missouri’s voters. Regional Hospital Controller Dana White explained that NRMC (Nevada Regional Medical Center) is a Disproportionate Share Hospital (DSH). “What that means is that we have a disproportionate share of self-pay, Medicare and Medicaid patients compared to other hospitals.” The hospital derives 75 percent of their revenue from those three sources. “I’m not an expert on Medicaid expansion, but I do know that it would help our hospital.”...Medicaid expansion would help them to stay healthy and be productive member of the community. That’s not specific to the hospital, that’s specific to the community as a whole.”...READ MORE