- 14 doctors, medical professionals among those charged in $258M fraud cases in 3 states (fiercehealthcare.com)
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
- Medicare to cover expensive cancer cell therapies (reuters.com)
...Centers for Medicare and Medicaid Services...said it has finalized a decision to cover expensive cancer cell therapies sold by Gilead Sciences Inc and Novartis AG...CMS...said it will cover the U.S. Food and Drug Administration-approved therapies when provided in healthcare facilities that have programs in place to track patient outcomes...The nationwide decision clears up “a lot of confusion” about coverage and will help patients get access to the novel therapies...CMS Administrator Seema Verma said...READ MORE
- Resort corridor hospital targeted by new Nevada law seeks to dispel misconceptions (lasvegassun.com)
A year after its opening and a few months after it was targeted in a political debate in the Nevada Legislature, Elite Medical Center...is looking toward 2021...That’s the year that Elite will have to accept Medicare and Medicaid, although CEO Patty Holden, who said it could be much sooner, hopes to work with lawmakers to create different classes of hospitals in Nevada...Less than a mile from Strip landmarks like the Bellagio and Paris Las Vegas, the hospital is working toward accepting Medicare and Medicaid, after state legislators earlier this year passed a law requiring essentially all hospitals in the state to accept the government programs...READ MORE
- Robin Hood to rescue of rural hospitals? New math promised on Medicare payments (lasvegassun.com)
As rural hospital closures roil the country, some states are banking on a Trump administration proposal to change the way hospital payments are calculated to rescue them...The goal of the proposal, unveiled by Centers for Medicare & Medicaid Services Administrator Seema Verma...is to bump up Medicare’s reimbursements to rural hospitals, some of which receive the lowest rates in the nation...By law, any proposed changes in the calculation of Medicare payments must be budget-neutral; in other words, the federal government can’t spend more money than previously allocated. That would mean any change would have a Robin Hood-like effect: increasing payments to some hospitals and decreasing them to others...READ MORE
- U.S. charges 58 in Texas with healthcare fraud, illegal opioid distribution (reuters.com)
Fifty-eight people have been charged with engaging in healthcare fraud schemes that centered on the illegal distribution of more than 6 million opioid pills across Texas...Some 16 medical professionals, including six doctors and seven pharmacists, were charged in the schemes, which featured one pharmacy in Houston that illegally dispensed more than 760,000 pills from March 2018 to September 2019…The schemes in Texas entailed Medicare fraud that resulted in more than $66 million in losses...They also included $158 million in fraudulent claims for compound creams and $23 million in tax evasion...Federal authorities have frozen $60 million in assets of the people accused...READ MORE
- CMS finalizes plan to boost wage index for rural hospitals (fiercehealthcare.com)
The Trump administration released a final rule...that boosts Medicare payments to rural hospitals in a bid to address major inequalities...The rules included an increase to the wage index for certain low-wage hospitals such as those in rural areas..."The changes we’re finalizing in today’s rule are long overdue and improve the way Medicare pays hospitals, which will help many rural hospitals maintain their healthcare labor force," CMS Administrator Seema Verma...READ MORE
- White House pulls drug rebate rule to relief of payers (biopharmadive.com)In win for pharma, Trump TV drug price rule struck down (biopharmadive.com)
The White House will withdraw a controversial plan to ban drugmaker rebates to pharmacy benefit managers in Medicare and Medicaid, stepping back from what the administration had once billed as "the most significant change in how Americans' drugs are priced at the pharmacy counter."..."Based on careful analysis and thorough consideration, the President has decided to withdraw the rebate rule...noting ongoing discussions about potential legislation around drug pricing...Drugmakers had supported the proposed rule, which fit with pharma's public relations campaign attacking the role played by PBMs in keeping drug costs high...READ MORE
- Medicare boosts CAR-T cancer therapies with expanded coverage (biopharmadive.com)
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
- Trump administration proposes rule requiring hospitals to publish the prices negotiated with insurers (cnbc.com)
The Trump administration is proposing a rule that would require hospitals to publish the prices that are negotiated with insurers or risk being fined...The proposed rule...would apply to the roughly 6,000 hospitals that accept Medicare. Hospitals could be fined up to $300 a day if the standard and negotiated prices for services are not posted online...Starting this year, the administration required hospitals to publish list prices, or the sticker price. That does not reflect what someone might pay with insurance. The proposed rule would go a step further and require hospitals to also post the prices various insurance plans pay...“We’re trying to change the paradigm here,” Centers for Medicare & Medicaid Services Administrator Seema Verma said...“We’re trying to ensure we have a competitive free market where providers can compete on cost and quality and patients have the information they need to seek high-quality providers.”...READ MORE
- CMS approves Washington request for ‘Netflix’ model to pay for hepatitis C drugs (fiercehealthcare.com)
The Centers for Medicare & Medicaid Services approved a request...from Washington state to negotiate value-based drug rebate agreements with pharmaceutical manufacturers in its Medicaid program...The approval makes Washington the fourth state to test such an arrangement; similar policies have already been given the OK in Oklahoma, Michigan and Colorado, according to an announcement from CMS...Washington officials are aiming to test a “subscription” model for hepatitis C drugs...In this model, Medicaid would pay a fixed annual sum to a drug company for the hepatitis C medication, purchasing an unrestricted supply of the drug... CMS is committed to increasing states’ flexibility to develop policies that lower costs, increase the predictability of expenses and improve access for patients...READ MORE