News for Insurers
Top stories summarized by our editors
11/20/2017

With no prior announcement, the FDA started appending meaningless, four-letter suffixes to newly approved biologics' nonproprietary names last week. Adding the suffixes represents an expansion of the FDA's practice of using them for the nonproprietary names of biosimilars.

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Regulatory Focus
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FDA
11/20/2017

Roche is counting on strong sales of multiple sclerosis drug Ocrevus, immunotherapy Tecentriq and hemophilia drug Hemlibra to offset losses on Avastin, Herceptin and Rituxan due to patent expirations.

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Reuters
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Roche, Roche, Tecentriq
11/20/2017

CMS officials decided not to move forward on its Shared Decision Making model after too few accountable care organizations signed up to participate. ACOs in the Medicare Shared Savings Program or Next Generation model would have received incentives to test a four-step clinical decision-making process for certain conditions.

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Health Exec
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CMS
11/20/2017

The Guideline Trustworthiness, Relevance, and Utility Scoring Tool developed at Tufts University School of Medicine can help clinicians identify practice guidelines that are trustworthy, relevant and useful, researchers reported in Annals of Family Medicine.

11/20/2017

Eighty-two percent of long-term and post-acute care organizations responding to a survey said they are struggling to participate in value-based care networks, and only 19% reported that they had at least some EHR capacity by the last quarter of 2017. In addition, 86% of LTC facility administrators said they do not exchange information electronically with referring hospitals and physicians.

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RevCycle Intelligence
11/20/2017

This year's Medicare extenders package includes the Increasing Telehealth Access to Medicare Act, a proposed bill set for passage that aims to expand telehealth coverage under Medicare Advantage plans. The bill calls for reimbursement of telehealth services at rates similar to in-person services starting in 2020 and access parity for such services in Medicare Advantage and Medicare part A and B programs.

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mHealth Intelligence
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Medicare, Bill
11/20/2017

Andrea Barrett of Virginia Beach, Va., and Georgia residents Matthew Harrell, Nikki Richardson and Tomeka Howard were charged on allegations of defrauding Medicaid through mental health counseling treatment companies they worked for or owned. The defendants allegedly stole the identities of mental health providers in Georgia and Florida and used them to submit over $3.7 million of fraudulent claims to Medicaid for unprovided services, resulting in around $2.5 million worth of improper payments, according to prosecutors.

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Patch
11/20/2017

Lakewood, N.J.-based Madison Avenue Pharmacy reached a settlement deal with the state comptroller office requiring them to repay Medicaid $878,083 for improperly billing the program. The pharmacy, which did not admit wrongdoing, was accused of submitting over 13,000 Medicaid claims without purchase invoices from January 2013 to February 2016, causing more than $1.4 million in overpayments, but the pharmacy was later credited with $538,744 after providing some additional documentation, according to the state comptroller's office.

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Madison Avenue Pharmacy, fraud
11/20/2017

Rachel Scharlepp, owner of PlayBig Therapy & Recreation Zone in Tallahassee, Fla., was charged last week with multiple counts of racketeering and Medicaid provider fraud and faces a maximum 85-year prison term and fines of over $528,000 if convicted. Scharlepp is accused of submitting over $100,000 worth of Medicaid claims and collecting over $88,000 for targeted case management services provided by unqualified employees, according to the Attorney General's office.

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Medicaid, PlayBig Therapy, fraud
11/20/2017

Stephen Guilbault, co-owner and office manager of Gulf South Physicians in Metairie, La., is facing a maximum five-year prison term after entering a guilty plea to conspiracy to commit health care fraud and illegally distribute drugs. Guilbault, who also agreed to pay restitution of $46,000 to Medicaid and Medicare, admitted to using prescription forms pre-signed by his physician partner to improperly prescribe dextroamphetamine, oxycodone and hydrocodone to himself and others.

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Gulf South Physicians, Medicaid