News for Insurers
Top stories summarized by our editors
10/18/2017

Health care policy experts Michael Chernew and Christopher Barbey suggest that accountable care organizations can produce three types of savings: utilization, payer and societal. Chernew and Barbey explore how each can be used as a framework for judging ACO success, arguing that early indicators suggest it's worth continuing to improve ACO models.

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ACO
10/18/2017

Primary care physicians at a rural tertiary medical center stopped making inappropriate referrals for cardiac catheterization after a training and screening program was implemented. Appropriate use guidelines were disseminated to physicians and specialists and posted in catheterization labs, advanced practitioners reviewed scheduled cases for appropriateness, and appropriateness was reconfirmed on the day of the procedure.

10/18/2017

A civil lawsuit has been filed by the Department of Justice against Ajibola Ayeni and Joy Turner-Ayeni, owners of Gateway Health Systems in Matteson, Ill., over allegations that they violated the False Claims Act by falsely billing Medicare for millions worth of unprovided or medically unnecessary home health care services. The lawsuit also alleges that another firm owned by Ayeni, called Docs at the Door, falsely certified non-homebound patients for unnecessary home health services and fraudulently upcoded doctor home visits to receive higher Medicare reimbursements.

10/18/2017

Anthony Enrico, a physician with practices in Paterson and Passaic, N.J., is facing up to 10 years in prison and $6 million in fines after pleading guilty to health care fraud for submitting $3 million worth of false claims to Medicare and private insurers. Enrico, who must also pay $3 million in restitution as part of his plea deal, admitted that he falsely billed Medicare and other insurance providers for more than 150,000 physical therapy services performed by unlicensed and unqualified employees.

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Anthony Enrico, Paterson, Passaic, N.J.
10/18/2017

Chicago resident Santila Terry, owner of Special Therapy Care Chartered in the city's Southwest Side, is facing Medicaid fraud charges over allegations that she improperly billed the program more than $909,000 for children's speech therapy services she did not provide. Terry allegedly used the personal information and Medicaid provider identification number of a former employee to execute the billing scheme from the time the employee left in September 2011 to November 2014, according to the indictment.

10/18/2017

Shawnnyce Dawson, owner of Sankofa Behavioral Health Agency in Las Vegas, Nev., received a suspended prison term of 12 to 48 months and was ordered to pay restitution of $50,324 on allegations that she defrauded Medicaid. Authorities said Dawson used fictitious documents to substantiate fraudulent Medicaid claims for services she didn't provide from January 2013 to March 2015.

10/17/2017

A federal judge invalidated four patents for Allergan's dry-eye drug Restasis, opening the door to possible generic competition, but no such drugs are approved yet, and the company said it will appeal. Allergan has been criticized for transferring patents for Restasis to a Native American tribe in an effort to protect itself from patent challenges.

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Allergan, Restasis
10/17/2017

Prohibiting ultra-high-dosage painkillers, restricting the marketing of opioids to treat chronic pain, improving access to alternative pain treatments, and intensifying efforts to squelch the supply of heroin and fentanyl are some steps the government could take to combat the opioid epidemic, according to former CDC Director Thomas Frieden and opioid policy researcher Andrew Kolodny. Frieden and Kolodny call for a twofold focus on "prevention of addiction among people not currently addicted, and treatment and risk reduction to prevent overdose and death among the millions of individuals in the United States now addicted."

10/17/2017

The Integrated Health Model Initiative is an integrated platform for clinical informatics and big data analytics being developed by the American Medical Association and its partners, including the American Medical Informatics Association, IBM and Cerner, and is designed to offer a collaborative approach for better population health management and chronic disease care. The platform, which will use existing data standards and will be developed and launched next year, will help the health care system in the collection, exchange and organization of patient-centered data.

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Health IT Analytics
10/17/2017

Rep. Tom Marino, R-Pa., withdrew his name from consideration to serve as head of the Office of National Drug Control Policy following a report suggesting that Marino advocated for legislation that weakened the government's capability to stop suspicious painkiller shipments from pharmaceutical firms, hampering its ability to fight the opioid epidemic. President Donald Trump said that he will follow through next week on plans to declare the opioid crisis a national emergency.