Compliance News Roundup: Medicare Advantage and Diagnosis Coding

1. Former CEO of Tennessee Pain Management Company Convicted for Role in Approximate $4 Million Medicare Kickback Scheme – “A federal jury sitting in Nashville, Tennessee found the former CEO of a Tennessee pain management company guilty today for his role in an illegal kickback scheme involving approximately $4 million in tainted durable medical equipment (DME) claims to Medicare.” Get the full scoop >>

2. Three Pharmaceutical Companies Agree to Pay a Total of Over $122 Million to Resolve Allegations That They Paid Kickbacks Through Co-Pay Assistance Foundations – “The Department of Justice today announced that three pharmaceutical companies – Jazz Pharmaceuticals plc (Jazz), Lundbeck LLC (Lundbeck), and Alexion Pharmaceuticals Inc. (Alexion) – have agreed to pay a total of $122.6 million to resolve allegations that they each violated the False Claims Act by illegally paying the Medicare or Civilian Health and Medical Program (ChampVA) copays for their own products, through purportedly independent foundations that the companies used as mere conduits.” Get the full scoop >>

3. Deeper Than the Headlines: Medicare Advantage and Diagnosis Coding – “Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) make predetermined monthly payments to MA organizations according to a system of risk adjustments that depend on the health status of each enrollee.  MA organizations are paid more for providing benefits to sicker enrollees than to healthier enrollees. To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. The OIG recently published the results of an audit they performed on an MA organization and found that diagnosis coding was not always correct. Let’s talk about what that means. Get the full scoop >>