Miami resident gets nine years for pharmaceutical scam; Watchdog says CMS routinely ignores improper payment recommendations

News From Around the Web

> A 24-year-old Miami resident was sentenced to nine years in prison and ordered to pay nearly $21 million in restitution for his role in a widespread pharmaceutical fraud scheme. Daniel Suarez co-owned eight pharmacies that submitted fraudulent claims to Medicare for drugs that weren't properly prescribed or provided to patients. Suarez and his co-conspirators paid kickbacks to patient recruiters in exchange for Medicare beneficiary referrals. The recruiters also bought the medically unnecessary prescriptions that were billed to Medicare. Announcement

> In a testimony to the U.S. Senate, Gene Dodaro, the comptroller general of the United States, said that many of the recommendations outlined by the Government Accountability Office go ignored by agencies like the Centers for Medicare & Medicaid Services. Dodaro specifically highlighted recommendations made by the GAO to improve coding discrepancies in Medicare Advantage plans that have led to as much as $5.1 billion in excess payments between 2010 and 2012. Testimony

> A doctor, a pharmacist, a pharmacy tech and a pharmacy owner in Texas were charged in a $17 million fraud scheme involving compounded creams that contained the powerful painkiller ketamine. Tamara Mitchell owned two pharmacies in Houston that allegedly used pre-signed prescriptions to sell compounding creams to customers with the "right" insurance plan. A physician, Michael Kelly, is accused of providing the pre-signed prescriptions in exchange for monthly cash payments, while a pharmacist and pharmacy tech allegedly marketed the creams to patients. Announcement

Health Payer News

> Employer health plans spend nearly twice as much on prescription drugs compared to the national average, leading Kaiser Family Foundation President and CEO Drew Altman to wonder if drug spending is "an even larger problem than many thought." Article

> The primary explanation for Affordable Care Act premium increases is simple: Insurers underestimated how many services ACA customers would use, which meant many companies ultimately paid more than they collected in premiums. For example, Blue Cross Blue Shield Tennessee paid $645 million in claims in 2014 and collected just $517 million in premiums. Article

And finally… We've hit a new low in judging pizza. Article