News for Insurers
Top stories summarized by our editors
9/20/2019

The cost for an individual health insurance plan for 2020 purchased from Maryland's health insurance exchange will decrease by an average of 10.3%, state officials said. The decrease was attributed to the $380 million health care reinsurance plan created in 2018.

9/20/2019

Fifty-eight people, including 16 physicians or medical professionals, were charged in Texas over their alleged roles in fraud schemes totaling $66 million that targeted Medicare, Medicaid, Tricare, private insurers and the Department of Labor's Office of Workers' Compensation Program. Among those charged are physician Craig Henry over his alleged role in a Tricare fraud scheme, and medical equipment firm executives Michael Braddick and Kyle Hermesch over their alleged involvement in a workers' compensation fraud case.

9/20/2019

Florida-based compounding pharmacy Diabetic Care Rx, also known as Patient Care America, its CEO, Patrick Smith, former executive Matthew Smith and private equity firm Riordan, Lewis & Haden agreed to pay over $21 million to settle a whistleblower lawsuit accusing them of violating the False Claims Act and defrauding Tricare. Authorities accused the defendants of paying kickbacks to third-party marketers in exchange for patient referrals, manipulating prescription formulations to ensure the highest reimbursement from Tricare and deliberately submitting fraudulent claims to the program, among other offenses.

Full Story:
Department of Justice
More Summaries:
Matthew Smith, Patrick Smith, Haden, Lewis
9/20/2019

Helen Storey, owner of Tallahassee, Fla.-based counseling center North Florida Mental Health, and the center's mental health counselor, Stephanie Fleming, are facing multiple charges including 75 counts of health care fraud and false statements in connection with a health care matter over allegations they conspired to defraud the state's Medicaid program. Authorities accused the defendants of submitting over $250,000 worth of fraudulent claims to Medicaid and its managed care organizations for unprovided health services, among other offenses.

9/20/2019

Kathleen Noftle, a resident of Tewksbury, Mass., has been charged with tampering with a consumer product and obtaining a controlled substance by misrepresentation, fraud, deception and subterfuge on allegations she stole morphine meant for patients while working as a nurse at Edith Nourse Rogers Memorial Veterans Hospital. According to investigators, Noftle admitted to stealing liquid morphine intended for patients by diluting the drug with water and ingesting some of the diluted morphine for herself.

More Summaries:
Morphine, Mass. hospital
9/19/2019

House Speaker Nancy Pelosi, D-Calif., today is expected to unveil a proposal to address prescription drug prices, and she is reportedly planning to move quickly on efforts to pass it. The bill is not expected to differ significantly from a draft framework leaked last week, and it could include provisions that would allow the US government to negotiate drug prices and link the costs of some US drugs to what's charged in other countries, sources say.

More Summaries:
Nancy Pelosi
9/19/2019

Rebates negotiated by pharmacy benefit managers and health insurers slowed growth in spending on brand-name medications in Medicare Part D by 15% from 2011 to 2015, according to a report from the HHS Office of Inspector General. The report looked at Part D reimbursement and rebates for 1,510 branded drugs from 2011 to 2015 and found total reimbursement for branded drugs increased to $65 billion from $55 billion during the period, while Part D rebate-adjusted reimbursement rose to $48 billion from $46 billion.

Full Story:
Healthcare Finance
More Summaries:
HHS
9/19/2019

Some commercial prescription drug plans and Medicaid drug benefit administrators are testing alternative payment models including subscription-type payments, reimbursement based on patient outcomes or fixed per-capita payments for a specific patient population. A study by researchers at Duke University's Margolis Center for Health Policy found that regulatory flexibility and clarity and better methods for measuring outcomes could increase the use of APMs.

9/19/2019

A group of senators asked the Federal Trade Commission to closely scrutinize proposed buyouts and mergers between large drugmakers and expressed concern that such deals will reduce innovation and enable drugmakers to raise prices.

Full Story:
Reuters
More Summaries:
Federal Trade Commission
9/19/2019

A new analysis from the Partnership for Health Analytic Research found hospital outpatient clinics keep 91% of gross profit margins from drugs administered by physicians to commercially insured patients, while physician offices collect 9% of gross profits. Hospital-owned practices also receive higher reimbursement than physician practices, have access to discounts like the 340B Drug Pricing Program and earn more from administering drugs than pharmaceutical firms that manufactured the medicines, according to the report.

Full Story:
Healthcare Finance