Category Archives: Pharmacy

MyCare Ohio Transition Continues

Ohio’s transition to Medicaid managed care continues. The Ohio Department of Medicaid, the contracting agency with the 5 managed care companies now providing services to Ohio’s dual eligible population is [providing more information to Ohio providers during this transition period. Those dual eligible (eligible individuals for both Medicare and Medicaid) are being transitioned into these managed care private sector insurance programs. Some providers have been experiencing technical difficulties in submitting claims under the new managed care systems and providers are frustrated with slow payments. An updated released by the Ohio Department of Medicaid provides some statistics by region on the number of submitted claims and percentages of paid claims within 30 days of submission. The information provides a link to the Provider Payment Technical Assistance program to work with providers on a case-by-case basis to assist in resolution of issues and to resolve payment concerns. The Ohio Department of Medicaid issuance that includes the Provider Payment Technical Assistance link can be found at http://healthtransformation.ohio.gov/LinkClick.aspx?fileticket=V9a0WTwYchs%3d&tabid=105

Supplemental Special Advisory Bulletin Clarifies OIG Positions on Independent Charity Patient Assistance Programs

Introduction

The OIG has released a Supplemental Special Advisory Bulletin that “reiterates and amplifies” previous OIG Special Advisory Bulletin guidance from 2005. Pharmaceutical manufacturers and Patient Assistance Programs that provide independent, charitable support for patients’ drug expenses (PAPs) should be aware of this supplemental guidance, as the OIG notes that it may modify some previously-issued favorable advisory opinions. Specifically, in this bulletin the OIG expands on its previous guidance regarding disease funds, eligible recipients, and the conduct of donors.

Background

PAPs provide cost-sharing assistance for patients who cannot afford their prescription medications. Continue reading

Office of Inspector General Issues Strategic Plan

The Office of the Inspector General (“OIG”) issued a 2014-2018 strategic plan including outlining the visions, goals, and priorities of that office for the upcoming several years. The plan sets forth four goals: 1. Fight fraud, waste and abuse; 2. Promote quality, safety, and value; 3. Secure the future; and 4. Advance excellence and innovation. Each goals is identified with several priority areas that support the stated goal. The report can be found at the OIG’s website http://go.us.gov/WdbV

Spring Cleaning – Dust Off Your Compliance Program Manual and Take Some Practical Steps to Reinvigorate Your Program.

Compliance program fatigue is nothing new. Over at least the last 15 years, health care organizations have jumped in head first, put together detailed manuals and taken the plunge. However, reimbursement cuts, quality initiatives, RACs, ZPICs, whistleblowers, physical plant renovations and simply significant industry challenges got in the way of sustaining an efficient and effective compliance effort. Health care organizations have also become desensitized to the barrage of compliance education, enforcement press releases, audits and reviews and other shock-value communications on the importance of regulatory compliance. In that vein, this very article may get lost in the shuffle, although, we hope it doesn’t.

An efficient and effective compliance effort with your organization is extremely important, if only as an insurance policy against government scrutiny. Additionally, the Patient Protection and Affordable Care Act of 2010, H.R. 3590 (“ACA”) includes requirements that CMS implement mandatory compliance program requirements for all providers and suppliers. In a distinct section of ACA, nursing home mandatory compliance programs were given a specific implementation timeline. Continue reading

Relator’s FCA Claims Barred By Public Disclosure Bar And For Failing To Be An Original Source

On January 25, 2013, the U.S. District Court for the Eastern District of Pennsylvania dismissed with prejudice the False Claims Act (“FCA”) claims that were alleged by a qui tam relator against two drug manufacturers because the whistleblower’s allegations were substantially similar to those that had been previously publically disclosed and the relater was not an original source of information.  The court then also declined to exercise supplemental jurisdiction over the remaining state law claims.  U.S. ex rel. Schumann v. AstraZeneca Pharmaceuticals LP, No. 03-5423, 2013 WL 300745 (E.D. Penn. Jan. 25, 2013).  The same court previously dismissed identical FCS claims against Bristol-Meyers Squbb Company in an earlier opinion.  U.S. ex rel. Schumann v. AstraZeneca PLC, No. 03-5423, 2010 WL 4025904 (E.D. Penn. Oct. 13, 2010). Continue reading

DAB: CMS Revokes Pharmacy’s Medicare Supplier Number After Owner Indicted

The DHHS Departmental Appeals Board (“DAB”) upheld the revocation of a pharmacy’s supplier number even after the tainted owner sold his interest to the remaining owner who was not involved in the fraud.  In Main Street Pharmacy, LLC v.Centers for Medicare and Medicaid Services, Docket No. C -10-359, Decision No. CR2160, June 18, 2010, the DAB Administrative Law Judge upheld the revocation because of findings that the pharmacy’s enrollment information with the National Supplier Clearinghouse was not timely updated to reflect the transfer to the non-tainted owner.

DAB Decisions Can Be Found at http://www.hhs.gov/dab/decisions/index.html