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It’s staggering to think of the challenges that CAHs face. Now OIG is calling for a re-examination of a program that it says has overpaid CAHs billions of dollars to provide skilled nursing services using hospital swing beds.

They’re called “Critical Access Hospitals” for a reason. These tiny healthcare outposts provide “critical access” to people who live in remote areas.

That was the intent of the legislation that created CAHs in 1997 at a time when rural hospitals were shuttering at an alarming rate. Congress understood that rural America needed extra Medicare dollars to keep the doors open at hospitals that serve an older, sicker and poorer patient mix.

It’s staggering to think of the challenges that CAHs face:

  • Because of their location and size, CAHs have few economies of scale, little leverage with vendors or payers, or a sufficiently large patient mix or volume of commercial payers to help cover costs.
  • CAHs are often limited in their ability to provide some of the more lucrative services that are cash cows for larger hospitals in urban areas.
  • Recruiting clinicians to rural areas is a slog.
  • And because of all those challenges, it’s also more difficult to merge or collaborate with other healthcare providers from such an isolated perch. It’s surprising to learn that only 40% of CAHs operate in the red.

Unfortunately, some people in Washington, DC have short institutional memories.

For the past couple of years, reports from the Office of the Inspector General at the Department of Health and Human Services have made it clear that they believe the CAH designation and funding scheme should be overhauled.

In its latest shot across the bow, OIG this week called for a re-examination of the swing bed program that allows CAHs to provide long-term care. The OIG audit claimed that the federal government has overpaid CAHs $4.1 billion over the past six years for services that could have cost less in relatively nearby skilled nursing and long-term care facilities.

Tavenner Pushes Back
Rural healthcare advocates rallied around the reply to the OIG recommendations from former Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner, who challenged the OIG findings and recommendations in her formal response, and suggested that auditors don’t understand healthcare delivery in rural areas.

In that same response to OIG, however, Tavenner said the Obama 2016 budget has called for reducing the Medicare reimbursement that CAHs receive from 101% to 100% of allowable costs, and reassessing and eliminating CAH status for hospitals that are within 10 miles each other.



Walgreens settles False Claims suits for $270 million

Two cases emerged from whistleblower claims about improper billing related to discounted drug prices and insulin pens.

Pharmacy giant Walgreens will pay nearly $270 million dollars as part of two major settlements, one that alleged the company had improperly billed federal healthcare programs for insulin pens it distributed to beneficiaries who didn’t need them and another that alleged Walgreens failed to disclose and charge lower drug prices offered through a discount program.

Both settlements were approved in mid-January and unsealed Tuesday. Walgreens must pay the United States and state governments a total of $269.2 million. Both cases arose from lawsuits filed by whistleblowers under the False Claims Act. Walgreens did not admit any wrongdoing as part of either settlement.


The DOJ said as a result of the conduct alleged in both cases, federal programs were inappropriately taxed. The alleged inappropriate disbursement of insulin resulted in the waste of valuable medication and created the potential for misuse “such as the improper resale of insulin pens on the Internet.” Because the company did properly disclose its discounted drug prices, federal healthcare programs paid out higher reimbursements than were actually warranted.


The first settlement resolved allegations that Walgreens improperly billed Medicare and other federal healthcare programs for “hundreds of thousands” of insulin pens dispensed to beneficiaries who didn’t need them. According to a statement from the Department of Justice, it was alleged that Walgreens programmed its electronic pharmacy management system to prevent its pharmacists from dispensing less than a full box of five insulin pens, whether the patient needed that amount or not. It also said Walgreens falsely stated that they had not exceeded limits set on total days of supply in its reimbursement claims. This settlement totaled $209.2 million.

In this case, the DOJ said Walgreens admitted that when a federal health program denied a claim because the reported days of supply for a full carton of five insulin pens exceeded the federal program’s days-of-supply limit, the company dispensed and billed for the full carton and reduced the reported days of supply to conform to the program’s days-of-supply limit. Walgreens also admitted that it “repeatedly” reported days-of-supply data to federal health programs that differed from the days-of-supply calculated according to the standard pharmacy billing formula.

The company will pay $60 million as part of a second settlement to resolve allegations it overbilled Medicaid by failing to disclose and charge Medicaid the lower drug prices that it offered the public through a discount program called the Prescription Savings Club. Legally, the company must seek reimbursement only for the “the lowest of certain drug price points, including the ‘usual and customary price'” namely the price offered through such programs as the PSC. Those prices were not disclosed, causing overpayment from Medicaid to Walgreens, the DOJ said. The agency also said that Walgreens admitted it did not identify its PSC program prices as its U&C prices for the drugs on the PSC program formulary, resulting in overpayments.


“Walgreens is pleased to have resolved these matters with the Department of Justice. The company fully cooperated with the government and has admitted no wrongdoing. Walgreens is a company of pharmacists living and working in the communities we serve, and we have always taken the safety and reliability of the medicines our patients need very seriously. We are resolving these matters because we believe it is in the best interest of our customers, patients and other stakeholders to move forward…In relation to these matters, Walgreens has entered into a Corporate Integrity Agreement (CIA) with the Office of the Inspector General of the Department of Health and Human Services. The CIA builds upon the company’s already existing comprehensive compliance program,” Walgreens said in a statement.

“In both settlements, Walgreens admitted and accepted responsibility for conduct the Government alleged in its complaints under the False Claims Act,” the DOJ said in a statement.

Three-fourths of Medicare Advantage denials overturned on appeal, OIG finds

Dive Brief:

  • An investigation by the HHS Office of Inspector General found large numbers of overturned denials upon appeal from Medicare Advantage organizations, raising concerns that some needed payments and services aren’t going to providers and patients.
  • Between 2014 and 2016, MAOs reversed 75% of their own denials, or about 216,000 a year, according to a report released Thursday. Additional denials were overturned by independent reviewers at higher levels of the appeals process.
  • The numbers are particularly troubling because of the infrequency with which beneficiaries and providers used the appeals process — for just 1% of denials at the initial appeal level, according to the report. 

Dive Insight:

The findings are important in light of the growing popularity of Medicare Advantage. Payers like the stability of the marketplace, and it’s popular with patients, too. In a recent Avalere Health study, MA beneficiaries with chronic conditions had 23% fewer inpatient stays and 33% fewer emergency department visits than people enrolled in Medicare fee-for-service plans.

That said, neither providers nor patients want to feel like they regularly have to appeal payment or service denials, especially with out-of-pocket costs on the rise.

Of the roughly 216,000 overturned denials, more than 80% were payments to providers for services the beneficiary had already received. The remainder — 18% — were for preauthorization of services not yet rendered.

But while some denials are justified, filing and processing appeals puts a burden on providers, MAOs and beneficiaries, especially those needing immediate care, OIG says. 

“Further, although overturned payment denials do not affect access to services for the associated beneficiaries, the denials may impact future access,” the report states. “Providers may be discouraged from ordering services that are frequently denied — even when medically necessary —to avoid the appeals process.”

OIG also points to CMS audits that show “widespread and persistent” problems with MAO denials of payment and care. In 2015, for instance, CMS cited more than half of audited contracts for inappropriate denials and 45% for sending incomplete denial letters. The latter could hinder efforts to successfully appeal a denial, the report notes.

While the agency imposed penalties and sanctions against the affected MAOs, more action is needed, the HHS watchdog says.

Specifically, OIG recommends CMS boost oversight of MAO contracts, with an eye toward identifying those with high overturn rates, and take enforcement actions when needed. The report also calls on CMS to address chronic issues around inappropriate denials and deficient denial letters and inform beneficiaries of serious MAO violations. 

CMS agreed to all three suggestions.


CHS subsidiary to pay $262M to settle fraud probe

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Franklin, Tenn.-based Community Health Systems subsidiary Health Management Associates has agreed to pay the federal government $262 million to settle fraudulent billing and kickback allegations.

The settlement resolves allegations that HMA billed government payers for inpatient services that should have been billed as less costly observation or outpatient services, paid physicians in exchange for referrals, and submitted claims to Medicare and Medicaid for falsely inflated emergency department facility fee charges.

HMA’s conduct occurred between 2003 and 2012, before CHS acquired HMA. HMA was facing multiple qui tam lawsuits and was the subject of criminal and civil investigations when it was acquired by CHS, and CHS cooperated with the government in its investigation.

“Since acquiring HMA in 2014, it has been our goal to resolve the government’s investigation into all of these allegations which occurred prior to the acquisition and which were already under investigation at the time of the transaction,” CHS said in a press release.

In addition to the $262 million settlement, HMA entered a nonprosecution agreement with the Justice Department. Under the NPA, the government agreed not to bring criminal charges as long as HMA and CHS cooperate with the investigation, report evidence of violations of federal healthcare offenses, and ensure their compliance and ethics programs satisfy the requirements of a corporate integrity agreement between CHS and HHS’ Office of Inspector General.

Under the settlement, Carlisle HMA, the HMA-affiliated entity that formerly operated Carlisle (Pa.) Regional Medical Center, agreed to plead guilty to one count of conspiracy to commit healthcare fraud. CHS divested Carlisle Regional in 2017.

“We are pleased to have reached the settlement agreements so we can move forward now without the burden or distraction of ongoing litigation,” said CHS. “As an organization, we are committed to doing our very best to always comply with the law in what is a very complex regulatory environment and to operate our business with integrity, ethical practices and high standards of conduct.”


Oxygen equipment provider Lincare pays $5.25M to settle Medicare Advantage fraud suit

The word fraud framed by other words

One of the country’s largest suppliers of oxygen and respiratory equipment has agreed to pay $5.25 million to settle allegations that it violated anti-kickback laws by reducing copayments for certain Medicare Advantage members.

Lincare has also entered into a corporate integrity agreement with the Office of Inspector General, the Department of Justice announced last week.

The settlement resolves allegations filed by former billing supervisor Brian Thomas, who worked for nearly a decade at the Florida-based company. In his 2015 complaint, which was later joined by federal prosecutors, Thomas claimed Lincare waived copays for Humana’s Medicare Advantage members beginning in December 2011 after the insurer contracted with Apria Healthcare to be an exclusive in-network provider of medical equipment.

In his complaint, Thomas said Lincare matched network benefits by reducing copays from Humana beneficiaries from 30% to 13% to align with copays from Apria. Humana was left paying for a higher charge using government funds.

Lincare was purchased by The Linde Group, a German industrial gas company, for $3.8 billion in 2012. The government alleged Lincare continued the scheme through 2017.

It’s the second major settlement for Lincare, which operates about 1,000 locations across the country. In May, the company paid $875,000 to settle a class action lawsuit from employers who had their information stolen during a data breach.




CHS faces investigation related to EHR incentive program

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Franklin, Tenn.-based Community Health Systems has received a civil investigative demand related to the company’s adoption of EHRs and adherence to the meaningful use program, according to CHS’ latest financial filing.

Under the meaningful use program, now called the promoting interoperability program, CMS distributed incentive payments to eligible providers for installing EHR systems and using them to engage patients and families and to improve care coordination.

In its financial filing, CHS said it is responding to a civil investigative demand related to its “adoption of electronic health records technology and the meaningful use program.”

Federal and state authorities issue these types of demands to collect records and information related to ongoing civil investigations, including False Claims Act cases.

CHS declined to comment on the investigative demand beyond what is included in the financial filing.

EHR incentive payments grabbed the attention of federal regulators after HHS’ Office of Inspector General released a report in 2017 that revealed Medicare made approximately $729.4 million in EHR incentive payments to medical providers who did not comply with federal requirements.


OIG: Acute care hospitals owe Medicare $51.6M, CMS agrees to provider clawbacks


A new government report finds that Medicare improperly paid acute care hospitals for outpatient services they provided to patients who were inpatients at other facilities. And now Medicare wants the money back

The Centers for Medicare and Medicaid Services has agreed to claw back the $51.6 million and require hospitals to refund patient copays and deductibles.

The Department of Health and Human Services Office of Inspector General audited (PDF) Medicare payments made between Jan. 1, 2013, and Aug. 31, 2016, and found that in that window CMS made $51.6 million in improper payments to hospitals for outpatient services provided to patients who were inpatients at long-term care facilities, critical access hospitals, inpatient rehabilitation facilities and inpatient psychiatric facilities.

Medicare typically would not pay an acute care hospital for outpatient treatments for a patient who is an inpatient at a different facility, according to the OIG, and instead the services should be rendered through an agreement between the two facilities, with payments going to the inpatient provider.

In addition, Medicare beneficiaries were responsible for $14.4 million in coinsurance and unnecessary deductibles paid to the acute care hospitals, the OIG found.

“Medicare overpaid the acute care hospitals because the system edits that should have prevented or detected the overpayments were not working properly,” the OIG concluded.

“If the system edits had been working properly since 2006, Medicare could have saved almost $100 million, and beneficiaries could have saved $28.9 million in deductibles and coinsurance that may have been incorrectly collected from them or someone on their behalf.”

OIG made three recommendations to CMS to resolve this issue:

  1. Recover the $51.6 million in inappropriate payments.
  2. Have the acute care hospitals refund the patients’ $14.4 million in coinsurance and deductibles.
  3. Identify improper payments outside of the audit window, and recover those as well.

CMS has agreed to these recommendations, OIG said.

OIG conducted the audit as previous investigations showed Medicare made inappropriate payments for outpatient services for people who were inpatients at acute care hospitals, and the organization wanted to see whether the trend extended to other types of facilities.

Shared Savings Program ACOs Reduced Medicare Spending by $1 Billion

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ACOs under CMS’ largest alternative payment model outperformed fee-for-service providers in quality and cost savings within the first three years of program.

According to findings reported by the Department of Health and Human Services Office of Inspector General (OIG), accountable care organizations (ACOs) participating in the Shared Savings Program are learning how to achieve greater cost savings over time. The Medicare Shared Savings Program is one of the largest alternative payment models implemented by CMS to reward providers for the quality and value of their services in order to keep patients healthy and lower costs.

The OIG’s report suggests many positive outcomes of the program, including that one-third of the ACOs that reduced their spending lowered costs enough to receive a portion of the savings. CMS data on quality measures also shows that ACOs generally improved the quality of care they provided, with a rate of 82% performance improvement on the individual quality measures within the first three years of the program. ACOs also outperformed fee-for-service providers on 81% of the quality measures.

A small portion of ACOs are reported to have gone above expectations, reducing Medicare spending by an average of $673 per beneficiary, including spending reductions for high-cost services such as inpatient hospital care and skilled nursing facility care. The OIG reports that these high-performing ACOs’ frequent use of primary care services, which can lower utilization and costs for other care, and cost reductions for services such as emergency department visits, was a factor in their cost savings. These strategies are compared to other Shared Savings Program ACOs and the national average for fee‐for‐service providers, who showed an increase in per beneficiary spending for key Medicare services.

The OIG concluded that ACOs show promise in reducing Medicare spending while also improving quality. These improvements come at a critical time, as Medicare spending is predicted to grow to $1.4 trillion by 2027. A large portion of Medicare spending has been attributed to overbilling, with the Medicare program losing more money to this error than any other program government-wide.

HHS announces ‘largest fraud takedown in history’

The Department of Health and Human Services Office of Inspector General, state and federal law enforcement executed a massive fraud takedown this month that charged more than 400 defendants in connection with healthcare fraud schemes that involved roughly $1.3 billion in fraudulent billings to government payers including Medicare and Medicaid, the OIG announced.

The takedown is being called the largest in history, both for the number of defendants charged and the amount of money lost, OIG said.

Additionally, OIG issued exclusion notices to 295 doctors, nurses, and other providers related to opioid diversion and abuse. The notices ban participation in or claim submissions to, all Federal healthcare programs.Those who got the notices include 57 doctors, 162 nurses, and 36 pharmacists.

“Takedowns protect Medicare and Medicaid and deter fraud — sending a strong signal that theft from these taxpayer-funded programs will not be tolerated. The money taxpayers spend fighting fraud is an excellent investment: For every $1.00 spent on health care-related fraud and abuse investigations in the last three years, more than $5.00 has been recovered,” OIG said in a statement.

The schemes spanned the entire nation, from Washington to Puerto Rico, and 115 of those charged are medical professionals, specifically doctors and nurses. Among the fraud schemes, a Texas provider was charged with overprescribing narcotics to patients who had no medical need for them, and some of whom died from drug overdoses. The doctor allegedly fraudulently billed Medicare, netting more than $1.2 million in reimbursement. Another scheme involved seven Michigan defendants, including five physicians, who allegedly perpetrated illegal kickbacks and billing for medically unnecessary joint injections, drug screenings, and home health services. One of the defendants owned multiple health-related businesses and allegedly billed Medicare $126 million as part of the fraud scheme.

Another notable fraud case recently announced by the Department of Justice involved a landmark settlement with historically unique requirements. Pharmaceutical manufacturer Mallinckrodt, one of the largest manufacturers of generic oxycodone, agreed to pay $35 million to settle allegations that it violated the Controlled Substances Act when it failed to report “suspicious orders” for controlled substances, as well as record-keeping infractions. The DOJ said that from 2008 until 2011, Mallinckrodt supplied distributors an “increasingly excessive quantity” of oxycodone pills but didn’t notify the DEA of these suspicious orders. The distributors then supplied various U.S. pharmacies and pain clinics.

The DOJ called the settlement groundbreaking for a couple reasons. First, it involves requiring a manufacturer to utilize chargeback and similar data to monitor and report suspicious sales of its oxycodone at the next level in the supply chain. This typically means sales from distributors to independent and small chain pharmacy and pain clinic customers. Also, it requires a parallel agreement with the DEA through which the company will analyze data it collects on orders from customers down the supply chain to identify suspicious sales.

It is clear government agencies and law enforcement are increasingly zeroing in on healthcare fraud, with other notable settlements in recent months with well-known providers related to False Claims Act violations. Those systems include Carolinas Healthcare, Freedom Health, Los Angeles hospital Pacific Alliance Medical Center, Genesis Healthcare, and even Walmart.

Editor’s Corner: OIG audit reveals dirty secrets about Meaningful Use

So far this year we’ve seen a shift in attention when it comes to electronic health records: less on the EHR Incentive Program, and more on the newer, more trendy issues, such as precision medicine, the Medicare Access and CHIP Reauthorization Act and ransomware.

But that old stalwart, Meaningful Use, is still a major focus, at least for the Department of Health and Human Services Office of Inspector General. And it should be for the rest of us, as well, based on what OIG has been unearthing.

The OIG issued its latest audit report on how states are paying Medicaid Meaningful Use incentives, and it isn’t pretty. The Arizona Health Care Cost Containment System made incorrect Medicaid incentive payments to 24 out of 25 hospitals reviewed, totaling almost $15 million in overpayments.