In Case Alleging Nationwide Pharmacy Fraud, Kmart Scores Narrow Settlement

David DouglassSean M. CuddihyBy David Douglass and Sean M. Cuddihy on Posted in False Claims Act, Healthcare

As described in an April 17, 2018 article originally posted on the Sheppard Mullin Richter and Hampton, LLP False Claims Act Defense Blog, Kmart Corporation and the U.S. Department of Justice entered into a False Claims Act settlement agreement dated March 8, 2018, to end an investigation that was conducted jointly by the United States Attorney’s Office for the Eastern District of California and California’s Bureau of Medicaid Fraud and Elder Abuse.

In a March 8, 2018 Press Release issued by the Department of Justice, the Department reported that the settlement was the result of a whistleblower lawsuit against Kmart in which the whistleblower, a Pharmacist-in-Charge at a California Kmart location in Lakeport, California, alleged that Kmart violated the federal False Claims Act by knowingly submitting claims for reimbursement to California’s Medi‑Cal program that were not supported by applicable diagnosis and documentation requirements.  As described in the March 8, 2018 Press Release, Kmart paid $525,000, as required by the Settlement Agreement; of this amount, $96,500 went to the whistleblower. Continue Reading

Medicare Advantage to Address Social Determinants of Health: An Important Step for Value-Based Care

Amanda ZablockiKristi KungBy Amanda Zablocki and Kristi Kung on Posted in Medicare Advantage

On April 4, 2018, the Centers for Medicare & Medicaid Services (“CMS”) finalized guidance and policies for the Medicare Advantage program that will expand the supplemental benefits afforded to beneficiaries to include items and services that address certain “social determinants of health” (“SDOH”). SDOH refers to a wide range of factors and conditions that are known to have an impact on healthcare, ranging from socioeconomic status, education and employment, to one’s physical environment and access to healthcare. Previously, CMS did not allow an item or service to be eligible as a supplemental benefit if the primary purpose was for daily maintenance. CMS’ reinterpretation of the statute to expand the scope of the primarily health-related supplemental benefit standard is an important step in encouraging value-based care. Continue Reading

Health Plans and Pharmacy Benefit Managers – Past and Future

Brian DaucherBy Brian Daucher on Posted in Healthcare

Historically, health plans and pharmacy benefit managers (“PBMs”) have been uncomfortable neighbors. Plans provide drug coverage, but contract out the provision of such drugs to independent PBMs. PBMs in turn earn market rents by negotiating discounts (and big rebates) with Big Pharma, in turn offering structured medication formularies to plans. Continue Reading

CMS Proposes “Wind Down” Plan for Federal Exchanges

Cody FierroMatthew GoldmanJordan GrushkinBy Cody Fierro, Matthew Goldman and Jordan Grushkin on Posted in Affordable Care Act (ACA), Centers for Medicare and Medicaid Services ("CMS")

Despite the Trump Administration’s unsuccessful attempts to fully repeal and replace the Affordable Care Act (the “ACA”), the Administration has continued to target the ACA. In the Administration’s latest salvo, the Centers for Medicare & Medicaid Services (“CMS”) announced in its Fiscal Year 2019 Performance Budget (the “Budget”)[1] – as released by the federal Office of Management and Budget on February 12, 2018 and as discussed in greater detail in CMS’s Justification of Estimates for Appropriations Committee released last week – a proposal to “wind down” its financial support for the federal health insurance exchanges. Specifically, the Budget explains that if Congress repeals the ACA, CMS will withdraw its support of the federal exchanges by plan year 2020. Continue Reading

Star Ratings and Future Measurement Concepts in the CY 2019 Final Call Letter

Lynsey MitchelErica KrausBy Lynsey Mitchel and Erica Kraus on Posted in Medicare

Medicare Part C and Part D Star Ratings are used by CMS to measure the quality of and reflect the experiences of beneficiaries in Medicare Advantage (“MA”) and Prescription Drug Plans (“PDPs”). Below is a summary of CMS’ proposed enhancements to the 2019 Star Ratings set forth in the 2019 Final Call Letter (issued by CMS on April 2, 2018) , as well as possible enhancements to the 2020 Star Ratings.

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California Sues Sutter Health Alleging Anti-Competitive Practices

David GarciaMatthew GoldmanJordan GrushkinSamuel GilkesonBy David Garcia, Matthew Goldman, Jordan Grushkin and Samuel Gilkeson on Posted in Antitrust

California Attorney General Xavier Becerra filed a civil antitrust lawsuit in San Francisco County Superior Court on March 29, 2018 (the “Complaint”), alleging that Sutter Health (“Sutter”), one of Northern California’s largest healthcare providers, engaged in unlawful conduct in violation of California’s Cartwright Act (the “Act”).[1]  Sutter Health has a substantial healthcare network that includes: 24 hospitals, 35 outpatient centers, physician’s organizations with over 5,500 members, and over 12,000 other physicians who partner with Sutter. Continue Reading

Blockchain for Healthcare

James GattoBy James Gatto on Posted in Blockchain, Healthcare Information Technology

Blockchain technology is finding its way into every industry. Healthcare is no exception. According to a recent report by Deloitte, “blockchain technology has the potential to transform health care, placing the patient at the center of the health care ecosystem and increasing the security, privacy, and interoperability of health data.” Some of the proposed applications include truly patient-centric health records, provider licensure and credentialing,  supply chain management in conjunction with predictive analytics and more accurate tracking capabilities, among many others. A recent whitepaper addresses “Innovative Blockchain Uses in Health Care” and an overview of blockchain technology. Just recently, Humana, MultiPlan, Optum, Quest Diagnostics and UnitedHealthcare announced a pilot program that will apply blockchain technology to improve data quality and reduce administrative costs around provider data management.  Continue Reading

Direct Primary Care Legislation Continues its Roll Across the Country: Florida Governor Rick Scott signs Florida House Bill 37, Direct Primary Care Agreements

Kenneth YoodSamuel GilkesonBy Kenneth Yood and Samuel Gilkeson on Posted in Direct Primary Care (DPC)

Direct Primary Care. Direct primary care (DPC) is a style of clinical practice in which a healthcare provider (usually a physician or a physician group) offers primary care services to patients who pay a monthly membership fee for the provision of primary care services at no additional charge to the patient/member. For its most ardent enthusiasts, DPC may best be described as it is on the Direct Primary Care Coalition’s home page:

Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee.  No fee-for-service payments.  No third party billing.  The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.  Patients have extraordinary access to a physician of their choice, often for as little as $70 per month, and physicians are accountable first and foremost to their patients.  DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country! Continue Reading

Take-Aways from CMS’ Recent Listening Session Regarding E/M Services: Documentation Guidelines and Burden Reduction

Lynsey MitchelBy Sheppard Mullin and Lynsey Mitchel on Posted in Centers for Medicare and Medicaid Services ("CMS")

On March 21, 2018, a representative from the Hospital and Ambulatory Policy Group at the CMS, held a listening session regarding proposed updates to documentation guidelines for Evaluation and Management (“E/M”) Services. The purpose of this listening session was for the agency to obtain stakeholder feedback in order to develop policy proposals for upcoming notice and comment rulemaking, which, according to the CMS, will require a multi-year, collaborative effort among the agency and providers. Despite the warning of a Sisyphean task ahead, the CMS seems focused on reducing the burdens associated with the documentation requirements, which date back to 1995. Perhaps the effort will be moot as documentation as the driver of reimbursement will be replaced with clinical and quality outcomes. While the industry is certainly on this path – moving from “if it is not documented, it has not been done” to “if there is no value, it has not been done,” coding remains key and the 20 year old guidelines must be re-visited in light of the current state of the practice of medicine, especially the wide-spread use of electronic health records (“EHRs”).   Continue Reading

New York Settles EmblemHealth Breach for $575,000

Kristi KungBy Kristi Kung on Posted in Privacy and Data Security

“New York Settles EmblemHealth Breach for $575,000,” is a reprint of an article first posted on the Sheppard Mullin Eye on Privacy blog on March 15, 2018. EmblemHealth is one of the United States’ largest nonprofit health plans. It is headquartered in New York City, New York.

New York Settles EmblemHealth Breach for $575,000

The recent $575,000 settlement with EmblemHealth signals a push from AG Schneiderman “for stronger security laws and hold[ing] businesses accountable for protecting their customers’ personal data.” Noting New York’s “weak and outdated” security laws, AG Scheiderman used the settlement to urge for the swift passage of the Stop Hacks and Improve Electronic Data Security Act (“SHIELD Act”) introduced by his office in November 2017, which would make New York one of the most protective states in terms of data privacy and security. Continue Reading

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