Payer Roundup—Pharmacy owner gets 15 years for $100M fraud scheme; BCBS Texas cracks down on ER coverage

Gavel court room lawsuit judge
A Florida pharmacy owner has been sentenced to 15 years and order to pay back millions for submitting false reimbursement claims. (Pixabay)

Pharmacy owner gets 15 years for $100 million Medicare scheme

A Florida pharmacy owner has been sentenced to 180 months in jail and was slapped with a $54 million restitution fee for his role in a massive compounding pharmacy fraud scheme, according to the Department of Justice.

Nicholas Borgesano, Jr., proprietor of A to Z Pharmacy, pled guilty last year to conspiracy charges related to the submission of false reimbursement claims to Medicare and private payers that generated about $100 million in fraud proceeds. While others in the scheme have been sentenced, Borgesano's was the most severe to date.  

Six additional people have been sentenced for their roles, with sentences ranging from one year to 66 months in prison. Another defendant is scheduled to be sentenced April 30. (DOJ)

BCBS Texas cracks down on ER coverage

Some Blue Cross policyholders in the Lone Star state will no longer be covered for emergency room services starting in June, unless it's a major emergency.

Blue Cross and Blue Shield of Texas beneficiaries will cover 100% of emergency room costs if their ailment is determined to not be serious enough, according to a memo obtained by Dallas Morning News. The new policy takes effect June 4 and applies to fully-insured groups and retail HMO members.

In the memo, the company said "some of our members are using the emergency room (ER) for things like head lice or sprained ankles... doing so not only drives up costs for our members, but uses limited ER resources for conditions that are not serious or life-threatening. We want to make health care affordable for our members." 

Emergency department charges for outpatient services are incredibly expensive, with the median charge totaling $1,233, according to the National Institutes of Health. (Dallas Morning News)

Piedmont, Anthem drama officially over

The beef between a Georgia hospital and an insurer over payments for 650,000 patients appears to be officially over. 

Piedmont Healthcare and Anthem Blue Cross of Georgia signed a new contract that retroactively covers the patients as in-network since the previous contract expired March 31. Since April 1, the beneficiaries were covered as out-of-network, meaning members would have been responsible for covering the higher costs.

During the standoff, which included an intervention by the Georgia governor, both sides deflected blame and pointed fingers at one another. The two informally came to a "handshake agreement" before the governor's deadline on April 17 for which he threatened executive action if a deal was not in place. Both sides officially signed the new deal April 20. 

The new contract extends into 2021. (Announcement)