| | | | |  | | By Chelsea Cirruzzo and Ben Leonard | | Presented by |  | | | With Robert King and Carmen Paun
| | |  An HHS audit has uncovered $11 million in overpayments to Humana's and CVS' Medicare Advantage plans. | Ed Reinke/AP | OIG: INSURERS SHOULD PAY FEDS MILLIONS — The federal government is asking Humana and CVS Medicare Advantage plans to pay $11 million in insurance overpayments, a new watchdog audit finds, Robert reports. HHS’ Office of the Inspector General conducted audits of medical claims paid out to Humana and CVS subsidiary HealthAssurance Pennsylvania. Humana and HealthAssurance disagreed with the findings, according to two press releases from OIG. OIG reviewed 240 diagnostic codes for Humana from 2017 through 2018. It found that 202 weren’t supported by medical records and CMS overpaid the plan $497,225. OIG is asking Humana for a refund of $6.8 million for the estimated overall amount for 2017 and 2018. OIG found that 222 of the 269 sampled diagnostic codes for HealthAssurance lacked the correct medical records, resulting in overpayments of $657,744. The response: Both Humana and HealthAssurance slammed the audit process, according to the audit. HealthAssurance said the audit was arbitrary, while Humana said the insurer followed CMS’ requirements. “Humana has consistently called for CMS to audit every plan, every year, using the right methodology that is consistent with the underlying principles of the Medicare Advantage model,” a Humana spokesperson told Pulse. HealthAssurance did not return requests for further comment. An OIG spokesperson told Pulse that the audit will go to CMS officials, who will assess any potential overpayments and decide whether to recoup them. Why it matters: OIG’s request for the full overall amounts shows the financial stakes for Medicare Advantage insurers and comes as such plans face more scrutiny from regulators and lawmakers who question whether CMS pays the privately run insurance plans too much. A March 2023 analysis from the Medicare Payment Advisory Commission, which advises Congress on Medicare issues, expected MA payments to increase by $27 billion in 2023 compared with traditional Medicare. CMS released a major rule in February 2023 to overhaul audits of MA claims. The rule retroactively applies the new audit process back to 2018 medical claims. One of the biggest changes in the rule is that CMS can extrapolate the results from a small sample of claims and apply it to the entire plan population, much like OIG has done in its audits. Humana filed a federal lawsuit last September to strike down the rule, which is still in litigation. WELCOME TO THURSDAY PULSE. Lyft scooters are officially leaving D.C. by Oct. 1 — and perhaps the injuries associated with them. Send your tips, scoops and feedback to ccirruzzo@politico.com and bleonard@politico.com and follow along @ChelseaCirruzzo and @_BenLeonard_.
| | | | A message from the Alliance for Fair Health Pricing: Hospital consolidation is driving up health care costs and threatening the autonomy of American physicians. Small, independent practices are disappearing, health care workers’ wages are shrinking, and patients are facing higher bills for the same care. Congress: physicians are counting on you to address unchecked hospital consolidation and rein in hospital monopolies’ abusive billing practices. Now is the time to protect the physicians who take care of us. Read our joint letter. | | | | | | | 
Following a request from Sens. Bill Cassidy (left), and Bernie Sanders, the Senate voted to hold Steward Health Care's CEO in contempt of Congress. | Kevin Wolf/AP | CRIMINAL CONTEMPT — The Senate agreed Wednesday to hold Steward Health Care’s CEO in contempt of Congress, directing the U.S. Attorney for the District of Columbia to prosecute Dr. Ralph de la Torre for failing to comply with the subpoena, POLITICO’s Daniel Payne reports. The resolution passed after Sen. Bernie Sanders (I-Vt.), chair of the Health, Education, Labor and Pensions Committee, and ranking member Bill Cassidy (R-La.) asked for unanimous consent. Background: The Senate vote comes after the HELP Committee voted 20-0 in favor of the criminal contempt resolution — as well as a civil contempt resolution, aiming to enforce the subpoena and bring de la Torre before the committee. Steward Health Care has been embattled after reports from journalists and Senate investigators alleged the health system gutted hospitals and left patients behind in pursuit of profits. Lawmakers have, at times, blamed Steward’s owners for patient injuries and deaths across the country — and for risking critical access to care in closing facilities. A spokesperson for de la Torre has previously denied wrongdoing. Steward Health Care declined to comment on the votes. Why it matters: The rare move marks a win for lawmakers looking to crack down on what they see as abuses by corporate health giants. It could also empower Sanders or other committee leaders to more aggressively use subpoena powers for bipartisan investigations. SHUTDOWN AVERTED — Congress approved legislation Wednesday to prevent a government shutdown, leaving federal agencies, including HHS, with static budgets through Dec. 20, POLITICO’s Caitlin Emma reports. House Speaker Mike Johnson once again relied heavily on Democrats to pass the measure, which punts spending fights to later this year. ‘TOO EARLY’ TO DECIDE ON CHAIR — Sen. Bernie Sanders (I-Vt.) told POLITICO’s Mackenzie Wilkes that it’s “too early to be talking about” whether he’d like to continue to chair the Senate health committee next Congress. “Let’s see what happens,” Sanders told Mackenzie on Wednesday. Sanders became chair of the Senate Health, Education, Labor and Pensions Committee at the start of 2023. In the past two years, he’s taken an aggressive approach to drug costs, pushing pharma executives to cut prices for commonly used items like inhalers and insulin. This week, the committee brought Novo Nordisk CEO Lars Fruergaard Jørgensen to the Hill to testify about the price of the company’s blockbuster diabetes and obesity drugs.
| | | | A message from the Alliance for Fair Health Pricing:   | | | | | GOOGLE GOES TO COURT — A judge has ruled that Google will go to trial in a civil case that involves the sharing of sensitive health data, including menstrual period cycle information collected by an app and shared with the company. California district judge James Donato rejected this week Google’s argument that the plaintiffs, who have said Google obtained and stored their reproductive health information without their consent, don’t have standing. Google has said the patients’ identities, which include period dates and sexual activity, among other data, were removed and the data can’t be tied to any plaintiff. Donato, however, sided with Google on the plaintiffs’ claim that the company has “aided and abetted” in the deceptive data collection policy, which the judge said Google didn’t appear to have knowledge of. How we got here: A class-action lawsuit was filed in 2021 against Flo Health, Inc., a menstrual and fertility tracker app, after it allegedly shared users’ information with third parties without their consent, including Google, Meta and others. Google had asked to be dismissed from the case. “Companies that use Google Analytics on their websites and apps own all data collected by the service and can delete that data at any time — Google only processes data as instructed by the customer. Additionally, Google does not allow personally identifiable information to be passed through Google Analytics. We don’t build advertising profiles from sensitive data like health conditions, and we have strict policies preventing developers and advertisers from using such data to personalize ads,” Google spokesperson Jose Castaneda told Pulse.
| | BUPE AND OPIOID ADDICTION — Adults who receive buprenorphine to treat their opioid use disorder may need higher doses than the ones recommended by the FDA, particularly if they use illicit fentanyl, suggests a new study funded by the National Institute on Drug Abuse, Carmen reports. The FDA recommends a buprenorphine dose of 16 mg a day. But researchers found that people taking higher daily doses — between 16 to 24 mg — had 20 percent longer times to emergency room or behavioral health visits than those on smaller doses. Why it matters: “The findings add to the growing evidence that higher doses of buprenorphine may have meaningful health impacts for people with opioid use disorder,” NIDA Director Nora Volkow said in a statement. Addiction to illicit fentanyl, which drove a record number of fatal drug overdoses during the height of the pandemic, has impacted treatment, with addiction providers saying people using fentanyl need higher doses of methadone, another drug used to treat opioid use disorder.
| | John Murphy is now chief executive officer and president of the Association for Accessible Medicines board of directors. He previously was chief policy officer at the Biotechnology Innovation Organization. Zuzana (Fedorkova) Love now works on technology portfolio strategy at the Office of Public Health Data, Surveillance and Technology at the CDC. She most recently was a digital service lead for the U.S. Digital Service. Cozen O’Connor has promoted eight members to shareholders: Alexandra Campau, managing director and director of health policy in Washington; Nathan Dooley, Commercial Litigation group; Kyle Farnam, Subrogation & Recovery department; Paul Ferland, Property Insurance group; Matthew Glavin, Public Strategies group; Aaron Lukas, Hatch-Waxman & Biologics practice; Dana Meyers, Subrogation & Recovery department; and Judd A. Serotta, Private Clients, Trusts and Estates group.
| | POLITICO’s Carmen Paun reports that a Senate committee has advanced legislation to strip the NIH of its authority to fund “risky research.” NPR reports that nursing aides are experiencing PTSD after treating nursing home patients at the height of the pandemic. The Washington Post reports that a 10th person has died amid a nationwide listeria outbreak.
| | | | A message from the Alliance for Fair Health Pricing: Unchecked hospital consolidation is not only driving up the price of health care for patients - it's taking a toll on physicians by limiting their autonomy, their choices, and their ability to provide affordable care to patients.
That’s why physicians, patients and employers are standing together to urge Congress to take immediate steps to protect doctors and ensure patients receive high-quality, affordable care.
These actions include codifying hospital and insurer price transparency to promote competition, establishing site-of-service billing transparency to prevent hospitals from overcharging, and implementing site-neutral payment reform to eliminate price disparities for routine services. These policies are crucial to promote competition and sustain independent physician practices. By prioritizing these policies, Congress can help create a more competitive health care market that protects physicians’ autonomy and lowers health care prices for patients. Here’s our joint statement. | | | | | | | Follow us on Twitter | | | | Follow us | | | | |
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