Government News of the Week
Medicare Compliance, HIPAA, Medicare Advantage and Part D,
Health Care Reform, and Other Federal and State Government Developments

October 27, 2014

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(1) The longstanding conflict between western Pennsylvania giants Highmark Inc. and UPMC erupted anew this month, with the battleground being a new Medicare Advantage product Highmark is introducing for 2015 .... (more)

  From the AIS Blogs
  The health insurance industry’s equivalent of the feud between the Hatfields and the McCoys sprung up again this month, and the new battleground is MA products for 2015. Who do you think is right in the Highmark-UPMC showdown? Join the conversation at the AIS Blogs.

(2) The U.S. District Court of Appeals for the Third Circuit on Oct. 20 dismissed a qui tam lawsuit accusing three pharmaceutical manufacturers of improperly inducing Medco Health Solutions, Inc. to offer certain of their drugs in the PBM’s mail-order pharmacies and in health plans it managed .... (more)

(3) CMS on Oct. 16 released the certification agreement and privacy and security agreement for qualified health plans to sign before doing business on federal exchanges for 2015 .... (more)

(4) Regence BlueShield, the largest health plan operator in Washington state, agreed to pay $6 million in two class action lawsuits over its exclusion of therapies for neurodevelopmental disabilities such as autism .... (more)

  From Congress and the Federal Agencies

(5) Two cardiologists agreed to pay $380,000 to settle false claims allegations that they had sham agreements with Saint Joseph Hospital in London, Ky., nine months after the hospital settled a false claims case for allegedly performing medically unnecessary cardiac procedures linked to the cardiologists’ practice .... (more)

(6) Medicare enrollment increased by 76,306 for the Oct. 1 payment date, reflecting enrollments received through Aug. 8, from the previous month .... (more)

(7) States that want to establish a Basic Health Program in 2016 now have guidance from CMS on the methodology for determining federal funding, which will equate to 95% of premium and cost-sharing subsidies that would have been provided to individuals through public exchange coverage .... (more)

(8) DaVita Healthcare Partners, Inc., agreed to pay $350 million to settle false claims allegations that it paid kickbacks to induce patient referrals to its dialysis clinics .... (more)

(9) A federal judge in Florida dismissed a False Claims Act lawsuit against Humana Inc., but indicated one claim may have merit .... (more)

(10) Private exchange builder Connecture Inc. has filed with the Securities and Exchange Commission (SEC) for its initial public offering on the Nasdaq Global Market .... (more)

(11) The October edition of CMS’s Medicare Quarterly Provider Compliance Newsletter has been issued .... (more)

(12) Cigna is suing Health Diagnostic Laboratory Inc. (HDL) for $84 million over what it calls “free forgiving,” in which the lab allegedly waived patient copays and inflated the insurer’s bills instead .... (more)


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