Payer Roundup—Feds indict CareFirst broker for $2M fraud scheme; OIG says 61% of PT claims were faulty

Money, handcuffs and a stethoscope
A D.C. man was charged with a fraud scheme that siphoned off $2 million from CareFirst. (Getty/Alex_str)

D.C. man charged with defrauding CareFirst

A former insurance broker for CareFirst Blue Cross Blue Shield has been accused by federal prosecutors of siphoning off $2 million for himself by using fake groups of insured individuals to obtain lower premium quotes and then marking up the premiums charged by the insurer. 

The indictment against Tarek Abou-Khatwa, also known as Dean Addem, was announced by the U.S. Attorney’s Office in the District of Columbia. Abou-Khatwa allegedly mixed fake names and real people with fraudulent birth dates to obtain lower premiums. (Announcement)

OIG says 61% of physical therapy claims were improper

Improper physical therapy payments cost Medicare $367 million over a six-month period in 2013, according to an Office of Inspector General report.

Reviewing a random sample of 300 claims, auditors identified issues with coding, medical necessity and documentation in 61% of outpatient physical therapy services. The OIG blamed the overpayments on a lack of effective controls by the Centers for Medicare & Medicaid Services (CMS) to monitor and identify improper therapy payments. CMS “generally disagreed” with the findings and took issue with a recommendation to instruct Medicare Administrative Contractors to notify providers about potential overpayments. (Report)  

Healthcare worries outpace crime, guns and drug use

More Americans “worry a great deal” about healthcare access and costs than issues about the availability of guns, crime or drug use, according to a new Gallop poll.

Fifty-five percent of Americans said they're very worried about the availability and affordability of healthcare, compared to 51% who say they worry about crime and violence, federal spending or the availability of guns. Less than a quarter of Americans say they worry only a little or not all about healthcare, tied for the lowest percentage with crime and violence.

Healthcare has been a consistent concern among Americans since Gallup began tracking it in 2001, although Democrats have generally voiced more concern than Independents or Republicans. (Poll)

Brand-name drug price growth outpaced inflation in the last 5 years

The price of some of the most popular brand-name medications has increased by 12% on average each year between 2012 and 2017, according to a report by the office of Sen. Claire McCaskill, D-Mo.

That growth rate is 10 times as fast as the rate of inflation. More than half of the drugs evaluated in the report increased 50% over that time period, and six increased more than 100%, driving $8.5 billion in profits for drug manufacturers despite a lower number of prescriptions. (FierceHealthcare)

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