News for Insurers
Top stories summarized by our editors
10/15/2018

Medicare Advantage enrollment is thriving, with sign-ups expected to rise 12% from about 20 million enrollees this year to 23 million for 2019. The CMS said consumers looking at options for 2019 can choose from about 3,700 plans, an increase of 600 from 2018, and low- or no-cost plans are among the options, along with improved benefits.

Full Story:
Kaiser Health News
10/15/2018

Seven Pennsylvania insurers including Capital Blue Cross, Geisinger Health, Highmark Health, UPMC Health Plan and Independence Blue Cross agreed to lift prior authorization requirements for medication-assisted treatment for patients with substance abuse disorders. The change applies to individual and group plans.

More Summaries:
Pennsylvania
10/15/2018

The problem of high drug prices is catching attention across the political spectrum and might be subject to rare bipartisan agreement on Capitol Hill. Sen. Chuck Grassley, R-Iowa, is likely to take control of the Senate Finance Committee if Republicans retain control of the chamber, and he has long appeared willing to take on Big Pharma.

10/15/2018

The Trump administration's so-called blueprint to reduce high drug prices consists primarily of modest regulatory actions aimed at increasing competition within the market and giving payers more negotiating power.

10/15/2018

Samsung Bioepis disclosed in a regulatory filing that Merck canceled a contract with the company to market a biosimilar version of Sanofi's Lantus insulin.

10/15/2018

Protections in the Affordable Care Act that ensure people with pre-existing conditions can get and keep health insurance are popular, but may be in jeopardy due to Republican attacks on the law. Republicans contend they have plans to replicate the ACA protections for patients with pre-existing conditions, but critics claim they would not be as comprehensive.

Full Story:
Kaiser Health News
More Summaries:
ACA
10/15/2018

Sheetal Kumar, a doctor from Stuart, Fla., was charged with 26 counts of health care fraud on allegations of defrauding Medicaid, Medicare and private insurers. Kumar, who pleaded not guilty to the charges, was accused of submitting or causing the submission of over $925,000 worth of fraudulent claims to private insurers, Medicare and Medicaid from January 2014 to July 2017, according to the indictment.

More Summaries:
Medicare, Medicaid
10/15/2018

Jeffrey White and his son Nicholas White, health care professionals from Twin Peaks, Calif., could each face up to 10 years in prison after pleading guilty to conspiracy to commit health care fraud for their involvement in a $27 million-plus health insurance fraud scheme. The Whites admitted to conspiring to defraud Affordable Care Act health plans in at least 12 states by fraudulently enrolling people in plans in states where they don't live, and then referring these patients to expensive residential abuse treatment programs in exchange for payments, which resulted in improper payments from health plans.

More Summaries:
Jeffrey White, Nicholas White, Whites
10/15/2018

Bharat Patel, a physician from Milford, Conn., received a prison term of four years and six months plus three years of supervised release after entering a guilty plea to health care fraud and conspiracy to distribute oxycodone and hydrocodone. Patel admitted to receiving $158,523.95 in exchange for writing hundreds of medically unnecessary prescriptions for oxycodone and hydrocodone, which resulted in improper payments from Medicare and Medicaid, while working at Family Health Urgent Care in Norwalk, Conn., from around 2011 to July 2017.

Full Story:
Department of Justice
10/15/2018

Tad Taylor, a doctor, and his wife, Chia Jean Lee, a registered nurse, could face up to 20 years in prison after being convicted of conspiring to distribute large quantities of controlled substances to people with no true medical need while jointly operating two Taylor Texas Medicine clinics in Richardson, Texas, from 2010 to 2012. An investigation found that Taylor unlawfully wrote 11,700 prescriptions for oxycodone, hydrocodone, alprazolam and other controlled substances for patients who didn't need them in exchange for cash payments from January 2010 to September 2011.

More Summaries:
oxycodone, alprazolam, hydrocodone