Suzan Berro submitted fake reimbursement claims to several drugmakers' co-pay assistance programs.
A Michigan woman has been convicted of wire fraud and related charges for her role in a years-long scheme to steal more than $65 million from several drug co-pay help programs, the U.S. Department of Justice says.
Suzan Berro, 23, of Dearborn, was convicted on Friday after a six-day trial in U.S. District Court in Detroit. She will be sentenced on May 1, when she faces a maximum of 20 years in prison on each count.
According to court documents and evidence presented at trial, Berro submitted fake reimbursement claims to several drugmakers' co-pay assistance programs that provide patients with "coupons" to offset the often-high costs of name brand prescription drugs.
Prosecutors showed that for nearly one year Berro was a biller for multiple pharmacies. She created fake prescriptions for fake patients using addresses from real estate lists, making up names and birth dates, selecting expensive name brand, and then ultimately pairing them with real doctors' names and credentials.
The evidence showed that the conspiracy went to great lengths to make the supposed patients appear real, including ensuring that all three addresses—the real doctor, the fake pharmacy, and the made-up patient—were in close, geographic proximity. However, witnesses said that most of pharmacies only existed on paper, were never opened to the public, nor did they order inventory.
Berro and her co-conspirators submitted bogus claims on behalf of more than 40 pharmacies, totaling over $65 million.
"This was a complicated scheme that abused dozens of programs established to help those who are legitimately unable to afford their medications," says Dawn N. Ison, U.S. Attorney for the Eastern District of Michigan.
Eli Lilly, Novo Nordisk, Sanofi, CVS Caremark, Express Scripts, and OptumRx are accused of overcharging patients.
California Attorney General Rob Bonta on Thursday filed a lawsuit against the nation's biggest insulin makers and pharmacy benefits managers, accusing them of using deceptive, illegal and unfair schemes to drive up the cost of the lifesaving drug.
The 47-page suit, filed in California Superior Court in Los Angeles, accuses drug makers Eli Lilly, Novo Nordisk, and Sanofi, and PBMs CVS Caremark, Express Scripts, and OptumRx, of leveraging their vast market power to overcharge patients, a violation of the state's Unfair Competition Law.
"Insulin is a necessary drug that millions of Americans rely upon for their health, not a luxury good," Bonta says. "With today's lawsuit, we're fighting back against drug companies and PBMs that unacceptably and artificially inflate the cost of life-saving medication at the expense of vulnerable patients."
Bonta is asking the court to order the defendants to stop their unfair business practices outlined in the suit and provide restitution for consumers who have been victimized by the scheme, and issue civil fines of $2,500 for each violation of state law.
More than 3 million Californians are diabetic, about 10% of the state's population, Bonta says, and their insulin is so pricey that many can't afford it, even the insured, and are forced to ration doses, sometimes with deadly consequences.
Those facts are in line with a 2021 report that found that insulin costs roughly 10 times more in the United States than in other countries. Other studies have shown that the high insulin prices disproportionately hurt poor people and communities of color. The California Department of Public Health reports that Hispanic and Black people are much more likely to be diagnosed with Type-2 diabetes than non-Hispanic white people, and much more likely to die as a result of complications from it.
"No one should be forced to ration or go without basic medication that could mean the difference between life or death," Bonta says. "California will continue to be a leader in the fight to ensure everyone has equal access to affordable healthcare and prescription medications they need to stay healthy."
The lawsuit notes that the three drug makers named in the suit produce more than 90% of the global insulin supply, and that the three PBMs manage 80% of insulin prescription claims. Using their market stranglehold, Bonta alleges, the defendants "work in lockstep… to keep aggressively hiking the list price of insulin at the expense of many patients."
The lawsuit asserts that manufacturers and PBMs are complicit in the gouging, with drug makers setting insulin's list price and PBMs negotiating for rebates on behalf of health plans. The rebates are based on a percentage of list price, so manufacturers raise their list prices to get the biggest rebates they can offer PBMs
"PBMs are often paid for their services with a portion of the rebate they have negotiated," the suit says. "This creates an incentive to negotiate a drug with a higher rebate, not necessarily the lowest price for consumers. As a result, the drug becomes unaffordable for uninsured or underinsured patients, who have to pay the full price of insulin. High list prices also make insulin unaffordable for other patients as well, including those with high deductible health plans or coverage gaps."
Defendents Respond
CVS Health issued a statement denying the allegations raised in the suit and saying it will "vigorously defend against this complaint."
"Pharmaceutical companies alone set the list price for their products," the company says. "Nothing in our agreements prevents drug manufacturers from lowering the prices of their insulin products and we would welcome such action. Allegations that we play any role in determining the prices charged by manufacturers are false."
A Novo Nordisk spokesperson says the drug maker does not comment on active litigation. However, the company issued a statement not specific to the suit which claims that Novo Nordisk's net prices for insulin have declined over the past five years "due in large part to the significant rebates and discounts manufacturers pay to ensure access for patients."
The company says that about 100,000 diabetics got free insulin from Novo Nordisk every year, and that more than 1 million get some form of financial assistance from the drug maker. The company has also extended its insulin program with Walmart that sells the drug for $25 per vial, and has seen "meaningful uptake" for its My$99Insulin program.
"However, we know there are people who continue to struggle to afford their insulin and that not one single solution will work for everyone," the statement reads.
Optum Rx issued a statement saying that PBMs negotiate for lower prices on behalf of consumers and "are the only participants in the prescription drug supply chain whose role is to reduce drug costs." The PBM says it has eliminated out-of-pocket costs on several prescription drugs, including insulin,
"Optum Rx welcomes the opportunity to show the California Office of the Attorney General, just as it has with other States Attorneys General, how we work every day to provide people with access to affordable drugs, including insulin," the statement reads.
Quadrupling the price of COVID-19 vaccine would make it too expensive for millions of Americans, the Vermont Independent says.
Railing against "unacceptable corporate greed," U.S. Senate firebrand Bernie Sanders is warning the billionaire executives at Moderna to "reconsider and refrain" from rumored plans to quadruple the price of their COVID-19 vaccine.
In a letter this week to Moderna CEO Stéphane Bancel, Sanders, I-VT, the incoming chairman of the powerful Health, Education, Labor and Pensions (HELP) Committee, expresses alarm about media reports that the drug maker will raise the price of its COVID-19 vaccine by as much as $110 to $130 per dose, more than four times the $26.36 cost that the federal government paid.
Sanders says the price hike is "particularly offensive" because the federal government directly provided $1.7 billion to Moderna's COVID-19 vaccine research and development, and guaranteed the company billions more in sales.
"The huge increase in price that you have proposed will have a significantly negative impact on the budgets of Medicaid, Medicare and other government programs that will continue covering the vaccine without cost-sharing for patients. Your decision will cost taxpayers billions of dollars," Sanders says in his letter.
"Your outrageous price boost will also increase private health insurance premiums. Perhaps most significantly, the quadrupling of prices will make the vaccine unavailable for many millions of uninsured and underinsured Americans who will not be able to afford it. How many of these Americans will die from COVID-19 as a result of limited access to these lifesaving vaccines?"
Moderna did not respond Wednesday to HealthLeaders' request for comment.
Sanders cites estimates that the cost of producing the vaccine is about $2.85 per dose – 2.2% of what Moderna plans to charge. At the same time, he notes that Moderna has pocketed more than $19 billion in profits off of the COVID-19 vaccine.
Top executives at Moderna have become billionaires off vaccine profits, Sanders notes, citing a Forbes estimates that Bancel is worth $6.1 billion, Moderna Chairman / Co-founder Noubar Afeyan is worth $2.1 billion; Co-founder Robert Langer is worth $2.2 billion; and founding investor Timothy Springer is worth $2.6 billion.
"Further, my understanding is that Moderna approved a $926 million golden parachute for you once you leave the company along with $160 million for Stephen Hoge (Moderna's president) and $53 million for Juan Andres (Moderna's chief technical officer)," Sanders writes. "The purpose of the recent taxpayer investment in Moderna was to protect the health and lives of the American people, not to turn a handful of corporate executives and investors into multi-billionaires."
Sanders says the "profiteering has taken place in the midst of the worst public health crisis in America in 100 years," with COVID-19 claiming 1.1 million Americans over the past three years, and sickening more than 100 million others.
"Now, in the midst of a continuing public health crisis and a growing federal deficit, is not the time for Moderna to be quadrupling the price of this vaccine," he writes. "Now is not the time for unacceptable corporate greed."
In a conference call Wednesday morning with reporters, Health and Human Services Secretary Xavier Becerra says the Centers for Medicare & Medicaid Services will publish the first 10 high-cost Medicare Part D drugs picked for negotiations on Sept. 1. The "negotiated maximum fair prices" for the drugs to be announced on Sept. 1, 2024, and the prices will take effect on Jan. 1, 2026.
Following the outline laid out in the Inflation Reduction Act, CMS will pick another 15 Part D drugs for 2027, 15 more Part B or Part D drugs for 2028, and 20 more Part B or Part D drugs for each year after that.
Lowering the cost of prescription drugs is a key component of the Act, which President Joe Biden signed into law in August, 2022. It gives CMS, for the first time in history, the authority to set drug prices, which Becerra says will lower out-of-pocket costs for millions of Medicare enrollees.
"Thanks to the Inflation Reduction Act, we finally have the authority to get American families the lower prescription drug costs they deserve," Becerra says. "Today we are releasing our plan for how we will implement Medicare drug price negotiation under this landmark law — and we will be transparent and aggressive in implementation every step of the way."
The program is fiercely opposed by the pharmaceutical industry. Pharmaceutical Research and Manufacturers of America (PhRMA) President / CEO Stephen J. Ubl in August blasted HHS’s newly bestowed authority, calling it "a partisan set of policies that will lead to fewer new treatments and doesn’t do nearly enough to address the real affordability problems facing patients at the pharmacy."
"We will explore every opportunity to mitigate the harmful impacts from the unprecedented government price setting system being put in place by this law," Ubl said. "We will continue to advocate for policies that give patients better and more affordable access to lifesaving treatments and for a system that supports innovation."
CMS Administrator Chiquita Brooks-LaSure says the negotiations will not be done in a vacuum, and that her agency "will engage with the public early and often," including Medicare and consumer advocates, drug makers, providers, pharmacies, and Medicare Advantage and Part D plans.
"We are proactively seeking feedback and insights from a broad range of interested parties throughout implementation of this historic law," she says.
Meena Seshamani, MD, CMS deputy administrator and director of the Center for Medicare, says public feedback will play a critical role in the successful implementation of the new law.
"Through this detailed timeline, we offer stakeholders the predictability they need to contribute to our implementation efforts," Seshamani says. "We want the public to know when and how they can make their voices heard on forthcoming policies."
IRA Savings Touted
Becerra also notes that Medicare enrollees are already feeling the financial benefits from several provision of the Inflation Reduction Act, including: free preventive Tdap and shingles vaccines; and a $35 monthly cap on out-of-pocket costs insulin.
In addition, the IRA requires drug makers to provide rebates to Medicare for drug prices that outpace inflation. That mandate took effect on Oct. 1, 2022 for Part D drugs, and Jan. 1, 2023 for Part B.
The IRA also authorized health insurance subsidies during its ongoing Marketplace Open Enrollment that the Biden administration says will enable 13 million people to save an average of $800 a year on health insurance premiums, and which has allowed four-out-of-five Healthcare.gov enrollees to find a plan for $10 or less after subsidies.
In contrast, in-person services for common mental health disorders dropped by more than half after the PHE was declared in 2020.
Telehealth for common mental health issues grew up to 20 fold in the first year of the COVID-19 Pandemic, more than compensating for a concurrent drop in in-person care for a number of conditions, a RAND Corporation study shows.
The RAND study is the first to show that the magnitude of the increased use of telehealth more than made up for the decline in in-person treatment.
An examination of more than 5 million privately insured adults, the researchers found that in-person services for depression, anxiety, bipolar, adjustment, and posttraumatic stress disorders dropped by more than half after the public health emergency was declared in 2020.
In sharp contrast, telehealth use grew steadily during the first year of the pandemic. By December of 2020, tele-mental health treatments for some disorders was 10% to 20% higher than in January 2020, according to the study, which was published in JAMA Health Forum.
“Our findings highlight a remarkable transition in the U.S. mental health system from in-person to virtual care,” says RAND economist Christopher M. Whaley, senior author of the study.
Other studies have documented an elevated level of psychological distress and mental health disorders such as anxiety and depression over the course of the COVID-19 pandemic.
Meanwhile, concerns about the spread of the coronavirus have led many mental health providers to eliminate or reduce in-person services.
In response, many providers switched to providing telehealth mental health services, and both public and private insurance providers expanded coverage for telehealth services.
To examine trends in tele-mental health, researchers looked at claims from commercially insured adults from January to December 2020, as provided by Castlight Health, a health benefit manager for employer-sponsored health insurance plans for about 200 employers in all 50 states.
The study found that the increased use of telehealth was lowest for bipolar disorder and highest for anxiety disorders.
When combining in-person and telehealth service treatment rates, there was an overall increase in care for major depressive disorders, anxiety disorders, and adjustment disorders. The increase in use of mental health services for anxiety disorders during the pandemic was higher for women than for men.
People in rural areas were less likely to use telehealth services, and people over age 46 also had lower rates of services than younger adults.
“While this may be partly due to a lower prevalence of certain conditions among older Americans, the consistency of this trend across different diagnosis categories suggests that factors such as lower digital literacy and less comfort with using telehealth also may play a role,” said Ryan K. McBain, lead author of the study and a policy researcher at RAND.
Support for the study was provided by the National Institutes on Aging and the Robert Wood Johnson Foundation.
The declines varied by regions, with larger drops in the South, Midwest, and West.
After a summer of relative stability, Telehealth use fell 3.7% this past autumn, from 5.4% of medical claim lines in September to 5.2% in October, according to FAIR Health's Monthly Telehealth Regional Tracker.
The declines varied by regions, with larger dips in the South (6.8%), Midwest (4.9%) and West (4.1%), contrasting increased use in the Northeast (1.7%), according to the FAIR data, which includes privately insured population, including Medicare Advantage but excludes Medicare fee-for-service and Medicaid.
Also in the report:
COVID-19 continued to fall among the top five telehealth diagnoses nationally and in most regions in October, as it had in September. Nationally and in the Midwest, COVID-19 fell from third to fifth place in the rankings. In the Northeast, it fell from second to third place, and in the South, it fell from fifth place out of the rankings.
In the West, COVID-19 had already been out of the top five telehealth diagnoses since September.
Acute respiratory diseases and infections climbed in the rankings of the top five telehealth diagnoses in October, following a trend that began in September.
In the Northeast, from September to October, this diagnosis rose from third to second place; in the West, it rose from fourth to second place. Nationally and in the Midwest and South, it remained at second place but increased in percentage share of telehealth claim lines. Nationally, for example, it rose from 3.1% of telehealth claim lines to 4.1%.
The rankings of the top five telehealth specialties did not change nationally or regionally from September to October, as social worker remained the number one telehealth specialty.
From September to October, the rankings of the top five telehealth procedure codes did not change nationally or in any region when compared to the previous eight months. The number one telehealth procedure code nationally and in every region remained CPT®2 90837, one-hour psychotherapy.
The Telehealth Cost Corner spotlighted the cost of CPT 90833, psychotherapy with evaluation and management visit, 30 minutes in October. Nationally, the median charge amount for this service when rendered via telehealth was $126.20, and the median allowed amount was $77.70.
Without insurance coverage, out-of-pocket costs for the drug will average about $26,500 per patient per year.
With the Food and Drug Administration granting fast-track approval on Friday of Eisai/Biogen's new Alzheimer's drug Leqembi, stakeholders are now urging the Centers for Medicare & Medicaid Services to follow suit and cover the pricey treatment.
The Alzheimer's Association called the FDA approval of the new drug for patients with mild cognitive impairment or in the early stages of Alzheimer's disease "a milestone achievement" for patients and their families. However, they warn that the cost of the drug – about $26,500 annually -- will limit access for many of the 6.5 million people in the United States who suffer from the disease. The advocates are pressing CMS to cover the costs.
"What the FDA did today in granting accelerated approval to Leqembi was the right decision. But what CMS is doing by severely restricting coverage for approved treatments is unprecedented and wrong," Alzheimer's Association CEO/President Joanne Pike, DrPH says.
"The FDA carefully reviewed the evidence for Leqembi before granting approval. CMS, in sharp contrast, denied coverage for Leqembi months ago before it had even reviewed this drug's evidence."
"CMS has never done this before for any drug, and it is clearly harmful and unfair to those with Alzheimer's," Pike says. "Without access to and coverage of this treatment and others in its class, people are losing days, weeks, months — memories, skills, and independence. They're losing time."
CMS Administrator Chiquita Brooks-LaSure says the jury is still out on the efficacy of Leqembi, which has shown moderate success during clinical trials.
"We will continue to expeditiously review the data on these products as they become available and are committed to timely access to treatments, including drugs, that improve clinically meaningful outcomes," Brooks-LaSure says.
FDA Approval
The FDA used its Accelerated Approval pathway to approve Leqembi (lecanemab-irmb) saying the drug, which reduces the beta amyloid clumps linked to Alzheimer's, "represents an important advancement in the ongoing fight to effectively treat Alzheimer's disease."
Billy Dunn, MD, director of the Office of Neuroscience in the FDA's Center for Drug Evaluation and Research, called the treatment "the latest therapy to target and affect the underlying disease process of Alzheimer's, instead of only treating the symptoms of the disease."
The FDA approval follows clinical research that included a double-blind, placebo-controlled, parallel-group, dose-finding study of 856 patients with Alzheimer's disease (three of whom died during the trial, although it's not clear if the drug played a role), and which showed a 27% reduction in cognitive decline over 19 months among patients receiving the 10 milligram/kilogram intravenous dose of the drug every two weeks, when compared with those who received the placebo.
Upon learning Friday that the FDA had fast-tracked Leqembi, Eisai/Biogen immediately submitted a supplemental Biologics License Application to the agency for a traditional approval.
Costs
Leqembi is not cheap, which Tokyo-based Eisai and Cambridge, Mass-based Biogen acknowledge. However, the drugmakers cite an Alzheimer's Association estimate that Medicare, Medicaid, commercial payers and out-of-pocket spending would increase from $267 billion in 2020 to $451 billion in 2030 if no treatments exist to delay the disease.
With effective treatments, however, the drugmakers say they can reduce the average per-person cost of treating Alzheimer's patients from about $37,000 to $26,500 annually, and that the cost could be further reduced to about $15,000 a year for ongoing maintenance once the treatment is underway.
New research published in the Journal of the American Medical Association (JAMA) finds that telehealth was superior to in-person care in 11 of 16 quality performance measures for primary care.
The study, conducted by researchers at the Robert Graham Center in Washington DC and Pennsylvania-based Wellspan Health, focused on more than 526,000 patients receiving healthcare services at roughly 200 Wellspan Health outpatient sites between March 1, 2020, and November 30, 2021, and used HEDIS (Healthcare Effectiveness Data and Information Set) measurements.
UnitedHealthcare Inc. members logged more than 28 million virtual care visits in 2021, a 2,500% increase over pre-pandemic usage, the payer says.
"While the COVID-19 pandemic triggered an unprecedented spike in the number of virtual care visits, we are seeing that telehealth has staying power even as many people have returned to in-person appointments," UnitedHealthcare CMO Donna O'Shea, MD, tells HealthLeaders.
"Virtual care visits in 2021 by UnitedHealthcare members approximately matched the total for 2020, with continued significant use of telehealth so far in 2022."
Only 1,714 of the 742,000 providers who billed Medicare and Medicare Advantage for telehealth services for about 28 million beneficiaries during the first year of the pandemic "posed a high risk" to the program integrity, a federal audit shows.
Now the not-so-good news.
These high-risk providers represent only 0.2% of the audit sample, but they billed for about 500,000 beneficiaries and collected $127.7 million in Medicare fee-for-service payments for care provided between March 2020 and February 2021, according to an audit by the Department of Health and Human Services, Office of the Inspector General.
Congress is halfway toward extending telehealth flexibilities enacted during the pandemic until the end of 2024.
The US House of Representatives this week passed the Advancing Telehealth Beyond COVID-19 Act of 2021 (HR 4040) by a 416-12 vote, sending the issue on to the Senate. The bill, introduced more than a year ago by US Rep Liz Cheney (R-Wyoming), expands the definition of "originating site" to allow more locations to use telehealth, eliminates facility fees for new sites, expands the list of healthcare providers able to use telehealth, adds audio-only telehealth to the definition of "telecommunications system," and makes permanent the ability of federally-qualified health centers (FHQCs) and rural health clinics (RHCs) to use telehealth under the Medicare program.
Vermont’s governor has signed into law a bill amending the state’s assisted suicide statute to include telemedicine.
S.74, passed by the state House and Senate after an almost two-year process and signed by Gov. Phil Scott on April 27, amends the state’s medical aid in dying law, which was passed in 2013, allows a patient who meets specific criteria to request a prescription to aid in dying through telemedicine, eliminating the need for two in-person consults and a 48-hour waiting period. The bill also establishes legal immunity for licensed healthcare providers, including pharmacists.
The bill defines telemedicine for these purposes as an interactive audio-video platform that complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
Newly introduced bipartisan legislation to improve healthcare access for Medicare and Medicaid beneficiaries would expand authority for advanced practice RNs (APRNs) to treat those patients.
The legislation does not provide full practice authority (FPA) in all 50 states—individual states govern those guidelines—but it does reduce a number of federal barriers that impede access to care for millions who receive healthcare through Medicare and Medicaid. Read more here.
New York is the newest state to grant nurse practitioners (NPs) full practice authority, joining 24 other states and Washington, D.C.
New York Gov. Kathy Hochul signed the state budget into law on Saturday, that includes legislation that eliminates the requirement for NPs to have a written practice agreement with a physician and allows them to provide the full scope of services they are educated and clinically trained to provide. Read more here.
Hospital emergency departments have been under severe strain during the coronavirus pandemic, according to a pair of new research articles.
The new studies examine boarding of patients in emergency departments before they are moved to inpatient beds and patients who left without being seen (LWBS), the latter presumably because of ED crowding and long wait times. The Joint Commission has deemed extended boarding of patients in the ED as a patient safety risk, with boarding recommended not to exceed four hours. Relatively high LWBS rates can have significant negative consequences for patients if they are deferring care for acute conditions. Read more here.
Factors such as ability to grocery shop, whether and how often they smoked, and the amount of certain cholesterol particles present in their blood can help predict how likely an individual over 70 years old will live two, five, or 10 years into the future, researchers at Duke Health have found.
"This study was designed to determine the proximal causes of longevity—the factors that portend whether someone is likely to live two or more years or 10 more years," researcher Virginia Byers Kraus, MD, PhD, said in a statement. "Properly applied, these measures could help determine the benefits and burdens of screening tests and treatments for older people." Read more here.
A significant number of temporary nurse aides (TNAs) may lose their jobs Friday if the Center for Medicare and Medicaid Services (CMS) doesn’t reissue a blanket waiver.
The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) have asked the Center for Medicare and Medicaid Services (CMS) to reissue the blanket waiver originally intended to allow nursing homes to employ temporary nurse aides beginning during the pandemic.
TNAs handle non-clinical tasks, serving as companions for nursing home residents. In June, the section of the 1135 waiver permitting their employment ended, giving them four months to become certified nursing assistants (CNAs), which would allow them to remain at their facilities. Read more here.
A primary care clinic start-up is differentiating itself by staffing its facilities only with nurse practitioners (NPs).
Minneapolis-based The Good Clinic chain is designed to emphasize patient engagement, continuity of care, and an emphasis on wellness and convenience through a unique nurse practitioner-driven model, says Larry Diamond, CEO of Mitesco Inc., which operates The Good Clinic brand.
More than half of U.S. states—26 states, Washington, D.C., and two U.S. territories—have granted patients full and direct access to care by NPs in adopting Full Practice Authority (FPA), according to the American Association of Nurse Practitioners (AANP). Read more here.
UnitedHealth is the target of a lawsuit by Envision Healthcare and several other physician practices, who claim the country's largest health insurer engages in a nationwide practice of low reimbursement rates for providers to force them out of network.
In doing so, UnitedHealth is allegedly driving physicians to its subsidiary, Optum, and paying providers at rates lower than the company offered for in-network.
Once UnitedHealth forces providers out of network, it allegedly pays the provider less than its billed charges and then charges the patient's plan a commission or surcharge for the savings. UnitedHealth, however, has no intention of paying the billed charges for out-of-network services and denies entitlement to payment for those charges. Read more here.
The No Surprises Act may have the unintended effect of causing millions more emergency department (ED) visits, according to a study from the Agency for Healthcare Research and Quality.
Since going into effect on January 1, 2022, the federal ban protects patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities.
The study, published in The American Journal of Medical Care, compares ED visits in 15 states with balance billing bans between 2007 and 2018 to ED visits in 16 states without bans to examine the ripple effects of a significant reduction in out-of-pocket payments under the No Surprises Act. Read more here.
Atrium Health—a Charlotte, North Carolina-based healthcare network with over 40 hospitals and $2 billion in net operating revenue—wants to turn its Harrisburg, North Carolina-based emergency room into a satellite hospital.
The health system submitted a "certificate of need" proposal to the Cabarrus County authorities for the $85.5 million expansion and is waiting on the state to approve the project.
"In an effort to bring high quality, convenient access to care to the residents of southern Cabarrus County that are already choosing AH Harrisburg for their health care needs, AH Cabarrus proposes to relocate 24 acute care beds and one operating room from its main campus to its existing Harrisburg hospital campus," Atrium said in a press release shared with HealthLeaders. "The proposed project also involves the replacement and relocation of an existing fixed MRI scanner to Atrium Health Harrisburg from Atrium Health MRI at its Concord Mills/Speedway location."
Additional inpatient, imaging, and surgical services will include 20 medical and surgical acute care beds, four ICU beds, a replacement CT scanner, a relocated and repaired MRI machine, fluoroscopy services, and the addition of a C-arm (a large, mobile imaging device) in the operating room.
The decision date for this project is set for the end of January. If approved, Atrium Health expects the satellite hospital to open on January 1, 2026. Read more here.
MA plans are under fire once again, this time with the introduction of new legislation that's aiming to take 'Medicare' out of the name.
The Save Medicare Act, sponsored by representatives Mark Pocan (D-Wis.) and Ro Khanna (D-Calif.), arrives just ahead of the open enrolment period, running from October 15 to December 7.
The bill would prohibit private insurers from using 'Medicare' in plan titles or advertising, and levy fines on payers that use the "deceptive practice."
"'Medicare Advantage' is just private insurance that profits by denying coverage and the name is being used to trick seniors into enrolling. That’s not right," Khanna said in a statement. "This bill will prevent these private insurers from labeling themselves as 'Medicare' and allow us to focus on strengthening and expanding real Medicare instead." Read more here.
The U.S. Department of Defense has awarded $136 billion for the "next generation" of TRICARE Managed Care Support Contracts that launch in 2024.
The T-5 MCS Contract maintains the requirement for two TRICARE regions in the United States – East and West. In addition, six states -- Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin with 1.5 million beneficiaries -- managed in the East Region will transfer to the West Region for a more equitable balance of the beneficiary population.
The $70.9 billion East Region T-5 MCS Contract was awarded to Humana Government Business of Louisville, KY. In the West Region the $65.1 billion T-5 MCS Contract was awarded to TriWest Healthcare Alliance of Phoenix, AZ. The new contracts will replace the T-2017 managed care contracts that provide care for the military and their dependents beginning in 2024.
"I am pleased that our new T-5 TRICARE contracts will continue to focus on enhancing the experience of care and great healthcare outcomes for our service members, retirees and their families," said Lt Gen. Ronald Place, director, Defense Health Agency.
The new contracts will continue to provide for the delivery of healthcare, customer service, claims processing and other administrative services to the estimated 9.6 million TRICARE beneficiaries. The new contracts do not change the TRICARE benefit and offer all the same TRICARE options.
"TRICARE is moving into a new era, making use of the lessons learned in the first three contract phases," Place says. "Defense Department leadership and the incumbent managed care support contractors are dedicated to managing a smooth transition to the new managed care support contractors, with minimum disruption to our beneficiaries."
The new contracts mandate improved integration between military medical facilities and the T-5 private sector care, with an emphasis on increasing interoperability with MHS GENESIS through Health Information Exchanges.
With T-5, beneficiaries can transfer care referrals when they move, whether their orders take them to a new duty station within their current region or to the other region. The DHA says that improving customer service also will be emphasized, with both regions required to reduce the average speed of answer calls to 20 seconds, matching general healthcare sector standards. In addition, the contract holders are mandated to improve call center resolutions and call backs, and first-call resolution requirements to align with industry standard for 85% of initial calls."
"We listened to our beneficiaries about what impacts their experience of care and address many of those concerns in T-5," Place says.
After the yearlong transition to T-5, military hospitals and clinics will have real-time access to medical management data, which increases data-sharing and promoting standardize care between civilian and military venues.
Blue Cross Blue Shield of Arizona says it will provide support for TriWest Healthcare Alliance’s new contract to administer the 26-state TRICARE West Region.
The U.S. Department of Defense's reconfigured "T-5" TRICARE program provides coverage for about active-duty service members, their families, National Guard and reserves and their families.