News for Insurers
Top stories summarized by our editors
2/19/2019

The expanded period for open enrollment in Affordable Care Act plans, enacted in dozens of Georgia counties due to Hurricane Michael, will end on Wednesday.

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ACA
2/19/2019

Sheetal Kumar, a doctor from Stuart, Fla., could face a maximum 10-year prison term after being convicted of multiple counts of scheming to commit fraud on health insurance claims for improperly billing Medicaid, Medicare and a private insurer. Authorities said Kumar submitted fraudulent claims to Blue Cross Blue Shield, Medicare and Medicaid from January 2014 to July 2017.

2/19/2019

Thelma Joiner, a former employee of Guam Medical Transport who was accused of attempting to cover up an ambulance fraud scheme allegedly committed by the private ambulance company, agreed to plead guilty to misprision of a felony and cooperate with the investigation. Authorities accused Clifford Shoemake and Kimberly Conner, co-owners of Guam Medical Transport, and Nicholas Shoemake, an executive assistant at the firm, of submitting fraudulent Medicare and Tricare claims for unneeded ambulance transportation services from March 2010 to March 2014, which resulted in $10.8 million worth of improper payments.

2/19/2019

Schlomo Schmuel, a podiatrist from California, and operator of two businesses in West Hollywood, surrendered to state insurance authorities on two counts of fraud for allegedly defrauding a private insurer. Authorities said Schmuel paid kickbacks to a marketer and medical provider in exchange for prescribing a hot/cold water unit to injured workers who didn't need it and then submitted inflated claims to a private insurer by using two Healthcare Common Procedure Coding System codes, which resulted in over $360,000 worth of improper payments.

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Patch
2/19/2019

Sentencing for Anna Ramirez-Ambriz, owner of Compassionate Medical Supply in Edinburg, Texas, who pleaded guilty to health care fraud for her role in a $4.5 million-plus Medicaid fraud case, was postponed for the seventh time to late April. Authorities said Ramirez-Ambriz submitted or caused the submission of over $4.5 million worth of fraudulent claims to Medicaid "for durable equipment which was not provided or not properly provided to Texas Medicaid recipients and/or was not authorized by a physician" from Jan. 5, 2007, to Nov. 19, 2013.

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Medicaid, Anna Ramirez-Ambriz
2/18/2019

Researchers found that people who have undergone surgery may be able to reduce their risk of developing methicillin-resistant Staphylococcus aureus infections by following an aggressive, six-month washing and sanitizing protocol once they are home. The study's findings were reported in The New England Journal of Medicine.

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Reuters
2/18/2019

An analysis of chargemasters at 34 hospital systems showed that average prices for commonly used outpatient drugs were three to seven times higher than average sales prices charged by Medicare. Academic hospitals had the greatest markups for both generic and branded medications, while generic drugs had higher markups than brand-name medicines overall, according to the study from AllianceBernstein.

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Axios, Fortune
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Medicare, AllianceBernstein
2/18/2019

A hearing on measles outbreaks affecting Washington, New York and Texas is being planned by the House Energy and Commerce Committee later this month. According to the CDC, there have been 101 confirmed measles cases in the US so far this year, and over 50% of those cases were recorded in one Washington county.

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The Hill
2/18/2019

CDC officials reported that 48 states had widespread flu activity during the week ending Feb. 9, while 26 states and New York City had high levels of activity. Outpatient visits involving flu-like illnesses reached 4.8%, while six additional pediatric deaths were documented, bringing the season total to 34, according to the CDC.

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CDC, flu
2/18/2019

Merck's Keytruda, or pembrolizumab, has been approved by the FDA as an adjuvant therapy for patients with melanoma who have lymph node involvement after complete resection. The approval is the 17th indication of the drug in the US.

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Seeking Alpha
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Merck, FDA, Keytruda, Keytruda