On May 1, a whistleblower filed a complaint under the federal False Claims Act (FCA) against Aetna, Elevance Health (formerly Anthem) and Humana alleging that the insurers paid hundreds of millions of dollars in illegal kickbacks to induce brokers including GoHealth, eHealth and SelectQuote (the “Brokers”) to steer beneficiaries to their Medicare Advantage plans. While
Lab Co-Owners Acquitted in Alleged COVID-19 Testing Scheme
A Florida jury recently found two laboratory co-owners of Innovative Genomics LLC (“IGX”) not guilty in connection with an allegedly fraudulent COVID-19 testing scheme.
The Government alleged that from November 2019 through June 2023, the co-owners conspired to defraud Medicare and the Health Resources and Services Administration COVID-19 Uninsured Program by billing healthcare benefit plans
The Status of Providing Gender-Affirming Care to Minors in NY
In recent months, Executive Orders issued by the current Administration regarding gender-affirming care of minors have been the subject of much debate and litigation. The crux of these lawsuits is largely two Executive Orders: Executive Order 14187 (Protecting Children From Chemical and Surgical Mutilation) and Executive Order 14168 (Defending Women From Gender Ideology Extremism and
NYS OMIG Publishes 2025 Work Plan
On January 29, the New York State Office of the Medicaid Inspector General (OMIG) published its 2025 Work Plan, which provides a preview of the OMIG’s program integrity initiatives for the upcoming year. While this post highlights several areas that the OMIG will focus on, Medicaid providers should refer to the Work Plan for
HHS-OIG Issues Nursing Facility Compliance Program Guidance
On November 20, 2024, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released the “Nursing Facility ICPG,” an industry-specific compliance program guidance for nursing facilities.
Background
The Nursing Facility ICPG serves as a voluntary, nonbinding tool to assist facilities in reducing risks related to fraud, waste, and abuse, while
Elevance Health Sues HHS and CMS Over Star Ratings System
On October 31, Elevance Health filed suit against the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) to challenge the 2025 Star Ratings system used for Medicare Advantage and Part D plans. CMS published the final Star Ratings to the public on October 10 through the
CA Physician and Practice Resolve FCA Allegations for $3.8 Million
The U.S. Attorney’s Office for the Southern District of California announced on October 11 that Dr. Janette Gray and her former medical practice, The Center for Health & Wellbeing in San Diego, resolved False Claims Act (FCA) allegations by agreeing to pay $3.8 million.
Gray and her practice allegedly billed Medicare and TRICARE from 2012
Lab Owner Pleads Guilty to COVID-19 Testing Fraud Scheme
On October 1, the U.S. Attorney’s Office for the Northern District of Illinois announced that Zishan Alvi, the owner of a Chicago laboratory, pleaded guilty to one count of wire fraud for his role in a COVID-19 testing fraud scheme.
Alvi pleaded guilty to causing claims to be submitted to the U.S. Department of Health
HRSA to J&J: Cease Implementation of New 340B Rebate Model
As previously discussed here, Johnson & Johnson (J&J) recently announced its intention to change its 340B Drug Pricing Program discount available to disproportionate share hospital (DSH) Covered Entities on purchases of STELARA and XARELTO. However, the Health Resources and Services Administration (HRSA) notified J&J that its rebate model was contrary to the 340B statute
J&J Announces New Rebate Model for 340B Program, but HRSA Pushes Back
On August 23, Johnson & Johnson (J&J) announced changes to its 340B Drug Pricing Program discount available to disproportionate share hospital (DSH) Covered Entities on purchases of two of J&J’s most popular drugs, STELARA and XARELTO.
As of October 15, J&J will make a 340B discount on these drugs available through a rebate. According to