RISE summarizes recent regulatory-related and news headlines.
Pharmacies, providers file lawsuit against Change Healthcare over cyberattack
The National Community Pharmacists Association, a trade group that represents 19,400 pharmacies, along with dozens of providers from multiple states, have filed a class action lawsuit against UnitedHealth Group and its subsidiaries Change Healthcare and Optum for losses resulting from the massive cyberattack earlier this year. The February ransomware attack disrupted payment and claims processing across the country for months. UnitedHealth paid $22 million ransom in Bitcoin to try and protect patient data that was compromised in the attack. It faces dozens of other lawsuits from providers over payment delays and patients who claim the breach put them at risk for identity theft.
Pharmacists and providers claim in the latest lawsuit that Change failed to take reasonable precautions against a catastrophic breach; misled them about its network security; and caused massive financial losses for health care providers who were never reimbursed for services and who incurred huge expenses trying to work around the downed system.
“UnitedHealth Group and its subsidiaries need to be held accountable for their lax security measures and for their failure to provide our members with adequate support and assurances to alleviate the financial losses our members suffered,” said NCPA CEO B. Douglas Hoey in a statement. “NCPA was against UnitedHealth’s acquisition of Change from the start. This breach proves that bigger is not better and that consolidation often leads to inefficiencies. Companies are so big they cannot protect every entry point and cannot respond quickly due to internal bureaucracy. The fact issues remain unresolved is a testament to this point. This breach has cost our members a significant amount of money and time and it is still not resolved months later.”
The lawsuit also noted that thousands of pharmacies had no way to process claims when the company shut down the system without providing a workable alternative. \
“Because Defendants disconnected the Change Platform, many health care providers lost their primary (and in some cases their only) source of claims processing for their patients and did not receive payment. Health care providers had to absorb these upfront costs,” says the complaint. In addition to the losses from not being paid, many pharmacies had to take out loans or deplete their reserves to buy expensive new software.
“Community pharmacies incurred the losses because they wouldn’t let their patients suffer,” said Hoey. “Senior citizens and people with chronic illnesses were especially vulnerable. They can’t afford to pay out of pocket for drugs that can cost thousands of dollars because a medical billing firm left itself vulnerable.”
“It wouldn’t have been fair to patients, and it isn’t fair to leave pharmacies holding the bag.”
Louisiana doc convicted for illegally distributing 1.8M doses of opioids and $5M health care fraud
A federal jury this week convicted a Louisiana physician for conspiring to illegally distribute over 1.8 million doses of Schedule II controlled substances, including oxycodone and morphine, and for defrauding health care benefit programs of more than $5.4 million.
Adrian Dexter Talbot, 58, of Slidell, owned and operated Sidell-La. Based Medex Clinical Consultants (Medex), a medical clinic that accepted cash payments from individuals seeking prescriptions for Schedule II controlled substances. According to court documents and evidence presented at trial, Talbot routinely ignored signs that individuals frequenting Medex were drug-seeking or abusing the drugs prescribed.
In 2015, Talbot took a full-time job in Pineville, La., and although he was no longer physically present at the Slidell clinic, he pre-signed prescriptions, including for opioids and other controlled substances, to be distributed to individuals there whom he did not see or examine. In 2016, Talbot hired another practitioner who, at Talbot’s direction, also pre-signed prescriptions to be distributed in the same manner at the Slidell clinic in exchange for cash deposited into the Medex account.
The evidence also demonstrated that Talbot falsified patient records to cover up the scheme. With Talbot’s knowledge, individuals filled their prescriptions using their insurance benefits, and health insurers, including Medicare, Medicaid, and Blue Cross Blue Shield of Louisiana were then billed for prescriptions that were written without an appropriate patient examination or determination of medical necessity.
The jury convicted Talbot of one count of conspiracy to unlawfully distribute and dispense controlled substances, four counts of unlawfully distributing and dispensing controlled substances, one count of maintaining a drug-involved premises, and one count of conspiracy to commit health care fraud. He is scheduled to be sentenced on Oct. 23 and faces a maximum penalty of 10 years in prison for conspiracy to commit health care fraud and a maximum penalty of 20 years in prison for each of the other counts.
MA members less likely to receive aggressive end-of-life care compared to Medicare beneficiaries
New research published in JAMA Health forum found Medicare Advantage beneficiaries were less likely to receive aggressive end-of-life care in last six months of life and more likely to receive hospice care.
Researchers conducted a retrospective analysis of Medicare claims data among older Medicare beneficiaries who died between 2016 and 2018. The study included Medicare decedents aged 66 years or older covered by traditional Medicare (659,135) or Medicare Advantage (360,430). All beneficiaries with one or more emergent hospitalizations with a life-limiting condition (cancer, dementia, end-stage organ failure) who would likely qualify for hospice care were included in the study. The study found that:
- Medicare Advantage members were less likely to receive potentially burdensome treatments or transfers in the last six months of life
- Medicare Advantage members were more likely to receive hospice care in the last six months of like
- If hospitalized in the last six months of life, MA members were more likely to die in the hospital and less likely to receive facility-based care post-discharge
Researchers said the findings suggest that Medicare Advantage plans have the potential to reduce burdensome treatments for patients approaching the end of life. However, they said it is not possible to establish if these findings align with patients’ preferences or provide appropriate care. In addition, the higher rates of discharge home after hospitalization may shift care burdens to informal caregivers if Medicare beneficiaries enrolled in Medicare Advantage plans lack adequate formal support services after a hospitalization.
But Medicare Advantage members account for rising share of inpatient hospital days
Another study published by KFF uses data from hospital cost reports submitted to the Centers for Medicare & Medicaid Services (CMS) to examine the growth of Medicare Advantage as a share of hospital inpatient days between 2015 and 2022.
Researchers found:
- Medicare Advantage grew from 13 percent to 23 percent of inpatient hospital days, and as of 2022, nearly half (48 percent) of all Medicare inpatient hospital days were attributable to Medicare Advantage enrollees.
- During this same period, the share of inpatient days attributed to traditional Medicare declined from 34 percent to 25 percent.
- The share of hospitals with more Medicare Advantage than traditional Medicare inpatient days grew from 5 percent in 2015 to 30 percent in 2022.
- The share of inpatient hospital days attributable to Medicare Advantage enrollees more than doubled in non-metropolitan counties between 2015 and 2022.
- Medicare Advantage inpatient day shares were highest in counties with higher Medicare Advantage penetration and lowest in those with lower Medicare Advantage penetration.