Medicare and Medicaid

On May 11, New York Gov. Kathy Hochul announced the establishment of the Pharmacy Benefits Bureau within the State’s Department of Financial Services (DFS). The Bureau will handle the licensing and supervision of pharmacy benefit managers (PBMs), and in particular their impact on consumers and the cost of healthcare. The Bureau will also have authority…

With the proliferation of precision and individualized medicine, genetic testing and counseling will likely remain on the radar of the Department of Health and Human Services’ Office of Inspector General (OIG) and the Department of Justice for years to come. Biopharma companies and manufacturers must carefully consider the facts and safeguards applicable to any sponsored…

Regulators are now better armed to cite and fine health plans that are not complying with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. A recent report to Congress highlights the enforcement work to date and illustrates the extent to which many plans are noncompliant with the law. The result is that…

The increased use of telehealth services is a trend that is expected to continue long after the COVID-19 pandemic ends. In keeping with this trend, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently issued a favorable Advisory Opinion that allowed a federally qualified health center (FQHC) to provide free…

A New York woman was sentenced last month to 78 months in prison for defrauding healthcare programs, including obtaining more than $6.5 million from Medicare Part D plans and Medicaid drug plans.

Queens resident Aleah Mohammed owned five pharmacies, four of which operated under variations of the name “Superdrugs.” Between 2015 and 2020, the pharmacies…

On April 20, the U.S. Department of Justice (DOJ) announced criminal charges against 21 people across the country for COVID-19-related frauds. The defendants are accused of over $149 million in false billings to federal programs and thefts from federally funded pandemic assistance programs.

Some of the defendants, in California, New York and Maryland, allegedly obtained…

In December 2019, the New York State Department of Health (DOH) issued a Request for Offers (RFO) from fiscal intermediaries (FIs) to enter into contracts with the DOH to provide FI services in the Consumer Directed Personal Assistance Program (CDPAP) for persons enrolled in Medicaid fee-for-service and Medicaid managed care programs. The CDPAP provides services…

On April 12, Department of Health and Human Services (HHS) Secretary Xavier Becerra extended the COVID-19 public health emergency for another 90 days. The PHE had been scheduled to expire on April 16.

The PHE originally went into effect in January 2020, at the onset of the pandemic. It provides important flexibilities for healthcare providers,…

The U.S. Department of Justice (DOJ) recently intervened in an action filed in Texas against two laboratory CEOs, one hospital CEO, and numerous other executives, employees, and recruiters, seeking civil penalties and treble damages for violations of the False Claims Act. The DOJ’s complaint, which was unsealed on April 4, also alleges that the fraudulent…

A March 21 article in Part B News, ACO REACH tweaks help smaller group practices, promote health equity,” discussed the Accountable Care Organization (ACO) Realizing Equity, Access and Community Health (REACH) model, which was announced on February 24 as a replacement for the CMS Global and Professional Direct Contracting (GPDC) model. Both programs are…