A pharmaceutical firm's recent decision to hike the cost of a prescription drug that treats foodborne illness from $18 to $750 per tablet outraged millions of Americans.

The move prompted Democratic presidential candidate Hillary Clinton to accuse the Swiss-American company Turing of "price gouging." The following day, Clinton unveiled her national plan to rein in drug prices -- and borrowed an idea from California: cap out-of-pocket costs for some prescriptions to save patients with chronic or serious health conditions thousands of dollars.

The Golden State's effort to tackle the issue of skyrocketing drug prices is among the most aggressive in the nation, opening up a wider debate over an industry whose sales account for 10 percent of the nation's $3 trillion in annual health care costs.

There seems little doubt that the controversy over rising drug prices will rage on and become a key issue in the presidential race. Though average generic drug prices have fallen by more than half since 2008, costs for the name-brand prescription drugs that treat chronic and life-threatening diseases have more than doubled over that period, up 127 percent, far more than the 11.24 percent inflation rate.

Read more at San Jose Mercury News

"Millennium Health LLC agreed to pay $256 million to resolve claims that it misrepresented the need for procedures and offered gifts to doctors in exchange for referrals.The biggest U.S. lab-testing company now plans to file for bankruptcy protection by Nov. 10, enabling it to turn over control of the business to its lenders, according to a person with knowledge of the matter.

The company has given the restructuring proposal to the holders of its $1.8 billion term loan and sent a copy to lawyers at the U.S. Department of Justice who are handling the settlement of the government’s case, said the person, who asked not to be named because the information isn’t public. Millennium will need to file its Chapter 11 petition with a bankruptcy court by Nov. 10, according to copies of resolved cases against the company that were unsealed Monday.

The payment will resolve allegations that Millennium violated the False Claims Act by having doctors order unnecessary urine, drug and genetic testing, according to a U.S. Department of Justice statement on Monday. The government accuses Millennium, a provider of urine-testing services to monitor prescription drug use and potential abuse, of misrepresenting to doctors the necessity of an $1,800 genetic test for pain management patients."

Read more at Bloomberg News

"The CMS says doctors tending to tens of millions of chronically ill Medicare patients aren't taking advantage of federal dollars aimed at improving care and reducing hospital readmissions and overall costs.

This year, Medicare began paying an average of $42 per patient per month for non-face-to-face chronic-care management services, such as consulting with other doctors caring for the same patient who might be dealing with dementia, heart disease or arthritis.

The CMS estimates 70% of Medicare beneficiaries—roughly 35 million—would be eligible, but CMS has only received reimbursement requests for 100,000 beneficiaries thus far, Kathy Bryant, a senior technical adviser in the Center for Medicare, said last week at an Advisory Panel on Outreach and Education meeting. She added that even that number may be too high as some could be duplicate claims.

One possible reason for the low interest is that doctors have to get permission from patients who are responsible for a 20% copayment each time their provider bills for the services.

“Getting bills for things when they haven't seen a doctor is not something they are used to,” Bryant said.

Others said the CMS didn't provide enough information on how to properly bill under the codes.

“Physicians are leery about using them because they don't know if they are doing so correctly,” said Regina Mixon Bates, founder and CEO of the Physicians Practice S.O.S. Group, a healthcare consulting and education firm. Another reason could be the lengthy process on electronic health-record systems."

Read more at Modern Healthcare

"Gov. Jerry Brown has signed legislation that requires weekly updates to health-service provider directories so people know what doctors and hospitals are in their network when they they shop for coverage or seek care.

Senate Bill 137 by West Covina Democrat Ed Hernandez responds to consumer complaints about inaccurate online directories. This has been a problem for years, but things got worse when thousands of consumers tried to pick a plan and provider after signing up for new insurance under the Affordable Care Act.

The problem got so bad that Covered California took its provider search tool down in February 2014. It still isn’t up — consumers are directed to individual health plan websites instead. The Department of Managed Health Care slammed Anthem Blue Cross and Blue Shield of California last year for failing to provide accurate provider lists. The agency is preparing to do follow-up surveys to see if inaccuracies have been fixed, spokesman Rodger Butler said."

Read more at Modern Healthcare

"WASHINGTON -- Two of the largest names in healthcare insurance are buying out their competition, triggering an investigation by the U.S. Department of Justice (DOJ) and expressions of concern from hospital and physician groups, as well as Congress.

In July, Aetna announced plans to acquire Humana for $37 billion. Just a few weeks later, Anthem revealed it was merging with Cigna in a $48 billion deal.

Critics say merging four of the five biggest insurers in the nation will kill competition, causing premiums to rise, benefits to narrow ,and provider payments to decline.

"Once [these deals are] consummated, there is simply no going back," said Andrew Gurman, MD, president-elect of the American Medical Association, in testimony before the House Judiciary Committee last week.

"You cannot unscramble an egg," said Gurman, who is an orthopedic hand surgeon based in Altoona, Pa.

Proponents of the mergers (namely, industry executives) argued that consolidating these four businesses would reduce administrative costs and expand networks, allowing companies to provide a broader array of products and services. The mergers would also accelerate the transition to value-based care and strengthen healthcare analytics, they said."

Read More at MedPage Today

Too many to post individually over the last few days:

Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery
California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme
Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims
Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case
Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid



Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery.

"WASHINGTON (AP) -- Bristol-Myers Squibb will pay $14.6 million to settle charges from U.S. regulators that its joint venture in China gave cash and other benefits to government health care providers to boost drug sales.

The Securities and Exchange Commission announced the settlement of civil charges Monday with the company, one of the largest drugmakers in the world. Bristol-Myers Squibb, based in New York, makes and sells prescription and over-the-counter medicines worldwide."

Read more at AP



California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme

"LOS ANGELES – A Placentia woman pleaded guilty Monday to a federal charge stemming from the operation of a hospice that submitted millions of dollars in fraudulent bills to Medicare and Medi-Cal.

Sharon Patrow, 44, entered her plea to a health care fraud count before U.S. District Judge S. James Otero, who set a May sentencing date. Patrow's mother, Priscilla Villabroza -- who is serving a 4 1/2-year term at a federal prison in Victorville for running a separate health care fraud scheme -- is also charged in the case.

The mother and daughter, along with four others, were charged in December with 25 health care fraud and money laundering counts, each of which carries a potential multiple-year prison sentence, according to the U.S. Attorney's Office.

The case involves the formerly Covina-based California Hospice Care, which Villabroza purchased in late 2007 while under investigation in the earlier case, prosecutors said.

Officials allege that between March 2009 and June 2013, California Hospice submitted nearly $9 million in fraudulent bills to Medicare and Medi- Cal for purportedly providing end-of-life care to patients who were, in fact, not dying. The public health programs paid nearly $7.5 million on those allegedly bogus bills."

Read more at OC Register



Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims

"COLUMBUS — Last week, the hospital business in Georgia’s second-largest city received a double dose of financial misery. The first round of bad news centered on Columbus Regional Health. State Attorney General Sam Olens announced Friday that Columbus Regional and other related entities had agreed to pay Georgia and the United States up to $35 million to resolve allegations of false Medicaid claims.

Then the Columbus Ledger-Enquirer reported Saturday that the other hospital organization in town, St. Francis, has been told by the feds that it must repay $21.4 million and make major changes in the way it does business. The federal audit report came 10 months after St. Francis said it could not account for about $30 million on its financial books."

Read more at Albany Herald



Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case

"A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes.


Guardian Hospice set aggressive targets to recruit and enroll patients it knew were not in the last months of their lives so it could collect Medicare payments, the federal government alleged. In agreeing to the settlement, the for-profit company, which serves the Atlanta area, did not admit liability."

Read more at AJC




Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid

WASHINGTON: Three health and safety net programs for the poor and elderly accounted for most of the federal government’s $124.7 billion in improper payments in fiscal 2014, the Government Accountability Office reported Thursday.

"The figure, which represents improper payments across 124 federal programs, is up roughly 20 percent from $105.8 billion in fiscal 2013, according to a new GAO report.

Most of the $19 billion increase resulted from erroneous payments under the Medicare, Medicaid and Earned Income Tax Credit programs. They account for more than 75 percent of the GAO’s government-wide improper payment estimate.

Improper payments are those made in error or in an incorrect amount and can include duplicate payments, those made without proper documentation or to ineligible recipients, and payments for ineligible goods and services.

They can result from fraud, unintentional clerical errors or a host of other reasons.

Nearly $1 trillion in improper federal payments have been made since 2003, when a federal law began requiring certain agencies to report the amounts."

Read more at McClacthyDC

'Nurses Registry and Home Health Corp. and the estate of its former owner, Lennie House, have agreed to a settlement against them for $16 million to resolve allegations of health care fraud, U.S. Attorney Kerry Harvey announced Thursday.
The settlement ends an investigation and False Claims Act litigation alleging that Nurses Registry, at the direction of House, fraudulently billed Medicare for medically unnecessary home health services, and services tainted by kickbacks provided by the company and House to local physicians and others who referred patients to Nurses Registry.

"For years, Nurses Registry abused its privileges as a provider in the Medicare program, and the trust of the medical community and general public," Harvey said in a statement. "This settlement returns ill-gotten gains to the Medicare Trust Fund and ensures that Nurses Registry will have no further opportunity to defraud federal health care programs."



Read more at Lexington Herald Leader