Menu Close

Tag: 2020 News

Amazon Launches Game Changing Online Pharmacy

A little over two years after its $753 million acquisition of the prescription medicine delivery service Pillpack, Amazon has finally launched Amazon Pharmacy, its online and mobile prescription medication ordering and fulfillment service.

The launch of the new Pharmacy service within Amazon is a blow to other discount prescription services like the publicly traded GoodRx and companies like RxSaver and delivery services like ExactCare Pharmacy.

The competition from Amazon was likely one reason why GoodRx began offering telemedicine services as a point of differentiation and to move up the value chain. It will be interesting to see if Amazon will also move to providing virtual care for more than its employees.

Last year, the company rolled out Amazon Care for its workers in Seattle as part of a pilot service that provided both in-person and telemedicine services.

Using a secure pharmacy profile, Amazon customers can add their insurance information, manage prescriptions and choose payment options all through Amazon’s service. And in another small push towards wider healthcare services, and not just selling items, users are provided with “self-service help” tools on Amazon’s portal, and they also have the option to speak to pharmacists either via over the phone, for advice: “Friendly and knowledgeable pharmacists are available 24/7 to answer questions about medications.”

After launching its own line of over-the-counter drugs in 2019, this is arguably Amazon’s broadest push into the healthcare business to-date, one that could open up very large, new revenue opportunities for the company, especially as the ongoing COVID-19 pandemic pushes consumers both toward more remote care, and using online channels for all their shopping needs.

While Amazon Pharmacy looks to be a US-only launch for now, it’s a global opportunity. Online pharmacy services are projected to hit revenues of $131 billion by 2025 worldwide. Prescription drugs, meanwhile, have been estimated to be a $904 billion industry this year, growing to nearly $1.3 trillion by 2025.

Amazon is also letting customers compare prices with their insurance co-pay, without insurance or with the savings available through the Prime prescription savings plan to choose the lowest option. Amazon is also staffing a pharmacy service accessible at all hours so that customers can answer questions about their medications.

In August, Amazon launched its fitness tracker, Halo. The personal health and wellness monitoring and advice service includes a $64.99 wrist tracker and an application suite for monitoring health.

Pfizer Starts COVID Vaccine Pilot Delivery Program

Pfizer has launched a pilot delivery program for its experimental COVID-19 vaccine in four U.S. states, as the U.S. drugmaker seeks to address distribution challenges facing its ultra-cold storage requirements.

Pfizer’s vaccine, which was shown to be more than 90% effective in preventing COVID-19 based on initial data, must be shipped and stored at -70 degrees Celsius (minus 94°F), significantly below the standard for vaccines of 2-8 degrees Celsius (36-46°F).

“We are hopeful that results from this vaccine delivery pilot will serve as the model for other U.S. states and international governments, as they prepare to implement effective COVID-19 vaccine programs,” Pfizer said in a statement on Monday.

It picked Rhode Island, Texas, New Mexico, and Tennessee for the program after taking into account their differences in overall size, diversity of populations, immunization infrastructure, and need to reach individuals in varied urban and rural settings.

The four states will not receive vaccine doses earlier than other states by virtue of the pilot, nor will they receive any differential consideration, Pfizer said.

The company expects to have enough safety data on the vaccine from the ongoing large scale late-stage trials by the third week of November before proceeding to apply for emergency use authorization (EUA).

Pfizer and its partner BioNTech SE 22UAy.F have a $1.95 billion deal to supply 100 million doses of the vaccine to the U.S. government, which has an option to acquire up to an additional 500 million doses.

Earlier on Monday, rival Moderna Inc MRNA.O said its experimental vaccine was 94.5% effective in preventing COVID-19 based on interim data from a late-stage trial, boosting hopes that vaccines against the disease may be ready for use soon.

Both the Pfizer and Moderna vaccines use a new technology called synthetic messenger RNA to activate the immune system against the virus.

CMS Webinars Clarify WCMSA Appeal Process

This year, CMS has been quite active announcing several updates to its Medicare Secondary Payer Recovery Portal and holding a recent webinar on redetermination requests. CMS trends regarding post-settlement Total Payment Obligation to Claimant (TPOC) beneficiary recovery have been causing some challenges for workers’ compensation carriers from another angle. CMS will also be holding a webinar on the NGHP Beneficiary Recovery Process on December 9th.

In September, CMS and the Commercial Repayment Center (CRC) held a webinar session to address “redetermination” requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). CMS reviewed the five levels of the administrative appeals process before the CRC discussed the various appeals available to primary payers in the administrative appeals process.

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

— Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
— Termination of ORM due to settlement or other claim resolution;
— Benefits denied/revoked by applicable plan;
— Non-covered services;
— Unrelated services; and
— Duplicative primary payment.

As part of this session, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand.

CMS’s trend of having the BCRC pursue the claimant post-settlement is currently causing some challenges and frustration particularly in workers’ compensation settlements.

Specifically, the BCRC is increasingly opening conditional payment recovery cases upon receipt of TPOC information and issuing final demands with the claimant named the debtor. This occurs even in situations where the parties have previously worked with the CRC to resolve conditional payment cases related to ORM.

When this happens, the carrier cannot interact with the BCRC on the claim without having a separate Proof of Representation (POR) executed by the claimant. This, in turn, complicates the workers’ compensation carrier’s ability to ensure that Medicare’s recovery is resolved if they cannot secure a POR from the claimant post-settlement.

To prevent this, workers’ compensation carriers wishing to ensure conditional payment exposure is fully resolved may need to consider securing a POR from the claimant as part of the settlement process to avoid having to chase the claimant post-settlement for this required authorization.

CMS has recently announced that it is holding a Non-Group Health Plan (NGHP) Beneficiary Recovery Process Webinar on December 9, 2020, at 1:00 p.m. ET. CMS indicates that its primary intended audience is “attorneys who represent beneficiaries and other beneficiary representatives.”

Huntington Park Clinic Owners Face $2.5M Fraud Charges

Ashot Mamikonyan and Lorraine Watson, the final two of nine defendants charged in an extensive fraud scheme involving All Care One Community Health Center in Huntington Park have been arraigned.

All Care One Community Health Center was located at 7300 Santa Fe Avenue in Huntington Park, California. Its NPI number is 1467752626.

In July, charges were filed against the defendants, all of whom worked for, owned, or were officers at All Care One. The group is alleged to have committed fraud amounting to over $2.5 million from California’s Family Planning, Access, Care, and Treatment (FPACT) program from 2014 to 2016.

From 2014 to 2016, All Care One was paid more than $5 million for FPACT claims. It is estimated that more than half of the $5 million was the result of fraudulent claims.

The alleged scheme involved sending staff to low income areas in Los Angeles to solicit people to provide their patient identifying information and a urine sample in exchange for a kickback. The personal information and urine were brought back to All Care One where medical assistants were instructed to falsify charts for these individuals, and then doctors, nurse practitioners, and midwives signed off on the charts as though they provided medical services related to family planning or sexually transmitted diseases.

All Care One marketers also allegedly offered kickbacks to lure individuals into the clinic for treatment, and many of these patients were treated by an unlicensed doctor.

In addition to Mamikonyan and Watson, felony charges have also been filed against seven other individuals involved in the scheme: Gevork George Ter-Mkrtchyan, Syuzan Harutyunyan, Karim A. Soliman, Guadalupe Morena Moreno, Jessica Villa, Maria D. Vasquez, and Anna Marie Soto. This group includes All Care One’s former owner, officers and employees.

Additionally, Mamikonyan was charged with the unlicensed practice of medicine, Harutyunyan was charged with aiding and abetting the unlicensed practice of medicine, and Moreno was charged with paying and receiving kickbacks.

Opioid Drugmaker Pays $2 Billion to Resolve Criminal Charges

Indivior Solutions was sentenced to pay $289 million in criminal penalties in connection with a previous guilty plea related to the marketing of the opioid-addiction-treatment drug Suboxone. The sentence was pursuant to a plea agreement.

In total, the payments made by Indivior Solutions and its parent companies, Indivior Inc. and Indivior plc, along with payments made under a 2019 resolution with Indivior’s former parent, Reckitt Benckiser Group plc, and criminal penalties paid pursuant to plea agreements with two former Indivior executives will exceed $2 billion.

That amount represents the second-largest monetary resolution obtained by the Department of Justice in a case involving an opioid drug.

Suboxone, which contains the powerful opioid buprenorphine, is a drug product approved for use by recovering opioid addicts to avoid or reduce withdrawal symptoms while they undergo treatment for opioid-use disorder.

In connection with its guilty plea, Indivior Solutions admitted to making false statements to the Massachusetts Medicaid program (MassHealth) related to the relative safety of Suboxone Film, a version of Suboxone, around children.

Indivior Solutions pleaded guilty on July 24, 2020, to a one-count felony criminal information charging false statements relating to health care matters.

Last June, Indivior’s former CEO, Shaun Thaxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. He was sentenced to a six-month term of incarceration and $600,000 in criminal fines and forfeiture.

Last August. Indivior’s former medical director, Tim Baxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. His sentencing is scheduled for Dec. 17.

Indivior Solutions that in October 2012 it sought to convince MassHealth to expand Medicaid coverage of Suboxone Film in Massachusetts and sent MassHealth a misleading chart and false data indicating that Suboxone Film had the lowest rate of accidental pediatric exposure (i.e., children taking medication by accident) of all buprenorphine drugs in Massachusetts, when in fact it did not.

Indivior Solutions further admitted that sending the false and misleading information occurred in the context of marketing and promotional efforts directed at MassHealth, which were overseen by top executives.

MassHealth announced it would provide access to Suboxone Film for patients with children under the age of six shortly after Indivior provided the false and misleading information to agency officials.

Claimant Faces Felonies for Lying About Pain History

30 year old Alexander Cody Smith, of Canoga Park was arraigned on three felony counts of workers’ compensation insurance fraud after allegedly misrepresenting past injuries to receive over $38,000 in undeserved medical treatments and temporary disability benefits from his employer’s insurance company.

Smith, while working for Engen Enterprises Inc., claimed he injured his back on March 16, 2018, as he was lifting a box.

Over the course of his medical treatment, Smith complained of back pain to his treating physician and later added complaints of neck pain to the claim. According to his claim and his doctor’s medical report, Smith denied any previous injuries or complaints about his back, specifically to his thoracic or lumbar spine.

An investigation by the California Department of Insurance revealed a history of medical complaints related to both Smith’s neck and back, which reportedly began in October 2015, according to subpoenaed records from his former health care provider and rehabilitation specialists.

The records show Smith received medical treatment from February 25, 2017, through March 13, 2018, and according to the records, it was at this time Smith reported feeling depressed due to his pain. This was just three days prior to the date he claimed he got injured at work while lifting the box.

The Department’s investigation revealed Smith misrepresented the history of his prior back injuries. Smith’s actions were likely made in an attempt to continue treatment for his ongoing condition, which was not work-related. Smith provided false information regarding his prior existing issues, which resulted in excessive and unnecessary medical evaluations, treatments, and temporary disability benefits at a cost of $38,746 to his employer’s insurance company.

Smith was arrested on October 28, 2020 and arraigned on October 30, 2020. The Los Angeles County District Attorney’s Office is prosecuting this case.

Stunning Public Mistrust in COVID Vaccine May Limit Protection

Many recent studies show stunning public mistrust in vaccines. And mistrust could push levels that potential COVID-19 vaccines are taken in the United States below the rates needed to protect communities against the disease.

One new prepublication study of 8,000 people in the U.S. and Britain found that fewer people would “definitely” take a COVID-19 vaccine than the 55% of the population scientists estimate is needed to provide so-called “herd immunity”.

The study comes as one of the major vaccine efforts showed promising results. Pfizer said on Monday its experimental COVID-19 vaccine is more than 90% effective based on interim data from late stage trials. The data were seen as a crucial step in the battle to contain a pandemic that has killed more than a million people.

People without a college degree, those in low-income groups and non-whites are more likely to reject a COVID-19 vaccine, the study found.

Women were more likely than men to refuse a COVID-19 vaccine, but more respondents in both countries said they would accept a vaccine if it meant protecting family, friends, or at-risk groups.

In the United States alone, another study by the Pew Research Center found, the share of adult Americans who say they would “definitely” or “probably” get a Covid-19 vaccine fell from 72 percent in May to 51 percent in September.

An October Harris poll showed that 78% of Americans think that the speedy approval process of a coronavirus vaccine is driven by politics – not by proof that shots work. About 83% said they would worry about a safe a coronavirus vaccine is if it was approved quickly.

And recent Axios-Ipsos polls confirms that vaccine resistance is growing. The percentage of people who say they are likely to get the first generation COVID-19 vaccine as soon as it is available fell from about 47% in August, to 39% at the end of September.

Heidi Larson, a professor at the London School of Hygiene & Tropical Medicine, who co-led the newest study said “This threatens to undermine the levels of COVID-19 vaccine acceptance.” She is also director of the international Vaccine Confidence Project.

NCCI MPN Cost and Outcome Study – Not All Good News

Medical provider networks for workers compensation have become increasingly popular over the last two decades. In conjunction with increased market penetration, some MPNs have broadened their services: As a way to improve outcomes, they do not just provide medical care, they manage the medical services on a claim, including interacting with the patient.

A new report published by NCCI looked at the impact of MPNs on workers compensation claim costs for 10 common WC injuries.

Comparing claims managed in-network to claims managed out-of-network across states and for 10 common injuries:

Average paid medical costs are higher in-network for the more costly back and shoulder injuries and lower for several less costly injuries.
In-network cases have more and higher-level office visits,as well as more physical therapy modalities,than comparable out-of-network cases.
— Except for the more costly back injuries, in-network claims (as compared with out-of-network):
— — Are less likely to be admitted to a hospital.
— — Cost less for hospital outpatient services.
— — Cost more for physician services.
— For all 10 injuries and for both permanent partial and temporary total claims, the average total incurred cost per claim for in-network claims is lower than, or about the same as, that for out-of-network claims.
In-network claims are more likely to have permanent injury awards than out-of-network claims; selection bias may play a role here
— WC medical costs for physician services are higher than comparable Group Health costs. The main driver of this difference is higher utilization of services to treat WC cases.
— For all but a few injuries with comparatively small numbers of cases, greater MPN penetration in a state is associated with greater MPN utilization of physician services in the state.

Differences at a state level may be considered in a follow-up study performed later.

CWCI Study Shows 36.2% Drop in Hospitalizations

A new study from the California Workers’ Compensation Institute shows the steep drop in the number of inpatient hospitalizations involving California injured workers over the past decade was largely due to the ongoing decline in spinal fusions and a more recent decline in lower extremity joint surgeries.

The study reviews discharge data compiled by the state Office of Statewide Health Planning and Development (OSHPD) on 35.9 million inpatient hospital stays from 2010 through 2019 paid by workers’ compensation, Medicare, Medi-Cal and private insurance, in order to identify workers’ compensation inpatient trends and to compare the volume and types of California inpatient hospitalizations covered by workers’ compensation to those covered by the three other systems.

Workers’ comp is by far the smallest of the medical delivery systems reviewed, accounting for just 0.4 percent of all inpatient stays in 2019, which is not surprising given that it has only accounted for between 1.4 percent and 1.6 percent of California healthcare costs over the past decade.

However, over the same 10-year span the study found that the number of workers’ comp inpatient hospitalizations declined 36.2 percent, more than twice the 15.9 percent decline noted for private coverage, and in sharp contrast to the 4.0 percent increase in Medicare and the 14.5 percent increase in Medi-Cal hospitalizations.

The study found that a key factor leading to the reduction of workers’ comp inpatient stays was the sharp decline in the number of injured workers receiving spinal fusions, which fell 53.1 percent between 2010 and 2019, a decline that was spurred by multiple factors including the adoption of utilization review and independent medical review programs requiring that treatment meet evidence-based medicine standards, the elimination of duplicate payments for implantable devices used in spinal surgeries, and fraud convictions that led to the sale of hospitals that had a high volume of workers’ comp back surgeries.

At the same time the overall number of work injury claims declined and there were technological and procedural advances that allowed more services to be provided in outpatient settings, prompting the growth of ambulatory surgery centers and an expansion of services at those facilities.

The study notes that spinal fusions were not the only type of workers’ compensation inpatient hospitalizations that saw a significant decline, as the number of workers’ comp discharges associated with lower extremity joint replacements has gradually declined in each of the past five years, falling from 2,727 workers’ comp discharges in 2014 to 2,140 in 2019, a net decrease of 21.5 percent.

In addition to tracking inpatient trends for California workers’ compensation, Medicare, Medi-Cal and private plans over the 10-year study period, the study also provides detailed data showing the breakdown of workers’ comp inpatient stays among the top 5 Major Diagnostic Categories (MDCs); the proportion of surgical vs. “medical” (non-surgical) hospitalizations in each of the 4 payer groups; the top 5 workers’ comp surgical and medical inpatient discharges by diagnostic-related group (MS-DRG) in 2019; the breakdown of the top 10 workers’ comp MS-DRGs across payer groups in 2019; the volume and prevalence of spinal fusion surgeries by payer group from 2010 through 2019; and the top 10 hospitals for workers’ comp inpatient care as well as the 10 hospitals with the highest ratio of workers’ compensation inpatients to total inpatients.

CWCI members and subscribers can access the report in the Research section and others can purchase it for $14 from the online Store. CWCI members may also log in to the Research section to access an updated version of CWCI’s Inpatient Hospitalization Claim Interactive Tool.

Travelers Launches Global Companion Plus+ for Foreign Risk

The Travelers Companies, Inc. announced the launch of Global Companion Plus+. This new product builds upon the company’s broad property and casualty offerings for U.S. firms with foreign exposures.

Features of Global Companion Plus+ include:

Primary Foreign Voluntary Workers Compensation: Protects employees who are working outside of their home countries.
— Financial Interest: Provides a separate $1 million limit for U.S.-based companies as an extra layer of protection when an eligible foreign subsidiary suffers a covered loss.
— Global Panel Counsel Service: Helps businesses in need of legal assistance abroad find in-country representation experienced in local regulations and languages.
— Emergency Evacuation Coverage: Offsets the cost of employees who must evacuate while abroad. This now includes coverage for natural disasters, political unrest and endemic disease.

“Even if a business does not have a physical foreign footprint, having international customers, worldwide vendors or employees who occasionally travel to different countries could create exposures that may not be covered by a typical domestic business insurance policy,” said Tony Giannone, Vice President of the Multinational Accounts Practice at Travelers. “We have updated our Global Companion Plus+ product to include a more robust offering that fills coverage gaps for our customers who could experience claims or lawsuits outside of the U.S.”

Travelers provides global coverage in conjunction with its strategic alliances in the International Network of Insurance (INI), which includes major international insurance companies from more than 150 countries. As the INI’s exclusive U.S. insurer, Travelers is able to offer customers access to experts around the world who have a deep understanding of local laws, regulations, customs and services, including specialized local claim professionals coordinated through Travelers’ Global Claim team.

INI Partners are independent insurers as well as experienced leaders within their respective markets. Each network partner is approved by the INI Board of Directors and follows the same contractual membership obligations and service guideless worldwide. Partners carefully picked based on defined criteria such as: financial strength, servicing capabilities and experience and claims handling expertise.

To learn more about Global Companion Plus+, visit