Monday, August 31, 2020

George Franklin Smith M.D.

 1948 - 2020

George Franklin Smith, M.D., 71, passed away on August 25, 2020 in Austin, Texas.

He was born November 25, 1948 in San Augustine, Texas.

George graduated with a Bachelor of Arts from the University of Texas at Austin, and then went on to earn his Masters of Science in Public Health from the University of Texas Health Science Center at Houston's School of Public Health.

He earned his Doctor of Medicine from the University of Texas Medical Branch at Galveston in 1977, where he was the presiding senior of the Phi Chi Medical Fraternity.

He practiced family medicine in Austin for a decade, during which time he held multiple leadership positions at St. David's South Austin Medical Center, including Chairman of the Board of Trustees. He then went on to serve as President of PCA Medical Group of Texas, P.A. and Vice President of Medical Affairs and then Executive Director of the Central Texas Market at PCA Health Plans of Texas, Inc./Humana, Inc. in Austin from 1990 through 1998, and then as Chief Medical Officer of HealthFirst HMO, Inc. in Tyler, Texas.

He rejoined Humana in San Antonio, Texas in 2001, where he served as Vice President and Chief Medical Officer for the South Texas market, and then as Regional President of Senior Products for the Southwest Region until his retirement in 2013.

He served in leadership positions in various professional organizations and was a great mentor to many colleagues. After his retirement he kept busy with consulting roles.

George lived life to the fullest. He had a passion for the outdoors, including hunting, fishing, hiking and gardening. He loved Texas Longhorns football and playing poker with dear friends. He also loved cooking for family and friends, hosting parties, and enjoying great food and wine with his fellow Chaine des Rotisseurs members. In his retirement, George spent much of his time traveling to new places near and far. A sixth generation Texan, descendant of The Old 300 and a member of the Sons of the Republic of Texas, he loved Texas and its history. He also had a passion for reading, and was taking seminar courses through the University of Texas's OLLI SAGE program.

He is predeceased by his parents, Leonard Louis Smith and Gladys Nichols Smith, and his first wife, Kelly Reynolds Smith. He is survived by his daughter Megan (Brad) Demicco of Dallas, son Garrett (fiancé Danelle Cantu) of Austin, grandchildren Andrew and Julia Demicco of Dallas, sweetheart Marilyn Davis of Austin, sister-in-law Morna Reynolds (Lee) Erwin of Knoxville, Tennessee, and many extended family members and dear friends. We will miss George's kind and generous spirit, great stories, and wonderful sense of humor.

In lieu of flowers, donations may be made to the University of Texas Medical Branch at Galveston or an animal rescue organization of your choice.

A celebration of George's life will be held at a later date.

Tuesday, August 18, 2020

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What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

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Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. 

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Thursday, August 6, 2020

Newly Unsealed FCA Suit Targeting Cigna Medicare Advantage

By Jeff Overley

Law360 (August 5, 2020, 9:39 PM EDT) -- Cigna Corp. overbilled Medicare Advantage by more than $1.4 billion by persuading nurses to diagnose policyholders with exaggerated medical problems, according to a newly unsealed suit that joins a growing list of False Claims Act cases targeting Medicare Advantage insurers.

The whistleblower suit made public Tuesday in New York federal court alleges that from 2012 to 2017 a company division called Cigna-HealthSpring billed for medical conditions that "did not exist, were not recorded in any medical records and were not based on any clinically reliable information."

Whistleblower Robert A. Cutler, an employee of Cigna contractor Texas Health Management LLC, filed the complaint under seal in 2017.

Whistleblower complaints under the FCA are usually unsealed only after the 
U.S. Department of Justice has announced whether it will intervene in the case. An order in February from U.S. District Judge Kenneth Karas said that the DOJ had declined to intervene in some of the allegations and would not intervene for the time being in the remaining allegations. The same order called for the complaint to be unsealed in April, but it only hit the docket on Tuesday for reasons that were not immediately clear.

Law360 on Wednesday afternoon asked DOJ representatives at the 
U.S. Attorney's Office in Manhattan to clarify whether the government would be intervening. Within 40 minutes, the entire case docket was again placed under seal on Pacer. A DOJ representative late Wednesday declined to comment on the status of intervention or the resealing of the case.

In a short statement Wednesday, Cigna also didn't say whether the federal government had decided to join the case.

"We are proud of our industry-leading Medicare Advantage program and the manner in which we conduct our business," the company said. "We will actively defend Cigna against unjustified allegations."

Cutler, who represented himself when filing the case, didn't immediately respond to an email and voicemail seeking comment on Wednesday.

Cutler's complaint focuses primarily on Cigna's arrangements with contractors that sent nurse practitioners to patient homes for health screenings.

"On numerous occasions, THM managers made clear to executives at Cigna-HealthSpring" that nurses couldn't definitively diagnose serious conditions, but Cigna went ahead and billed Medicare Advantage as if the assessments were "confirmed medical diagnoses," the complaint alleges, referring to Texas Health Management.

Cutler's suit describes one instance of billing codes being added for dementia and chronic obstructive pulmonary disease even though a nurse practitioner reported that a patient's mental and respiratory functions were normal. In another section, the suit describes Cigna training contractors to diagnose rheumatoid arthritis based solely on fatigue, weight loss and certain symptoms of pain and stiffness.

The government was "unaware that these claims were false and fraudulent," and it "overpaid Cigna-HealthSpring by more than $1.4 billion," the complaint said of claims submitted over the five-year period.

Cigna paid $3.8 billion in 2012 to acquire HealthSpring Inc., which at the time had 340,000 Medicare Advantage enrollees. There are 22 million enrollees nationwide among all Medicare Advantage insurers, and Cigna is a relatively small player in the space, according to the Kaiser Family Foundation.

Medicare Advantage insurers are paid more than $200 billion annually, and FCA litigation against them by the DOJ is a relatively new phenomenon. The DOJ joined two whistleblower cases in 2017 against 
UnitedHealth Group Inc., which has defeated one of those cases and trimmed allegations in the other one. More recently, the DOJ in March hit Anthem Inc. with allegations of Medicare Advantage fraud.

All the cases involve allegations that insurers overstated the severity of illnesses to get more money from the government. Cigna noted in its most recent annual report that the DOJ "is conducting an industrywide investigation of Medicare Advantage" billing by insurance companies. Cigna added that it was "currently responding to ... civil investigative demands received from the ... U.S. Attorney's Offices for the Eastern District of Pennsylvania and the Southern District of New York."

Counsel information for the government and Cigna were not immediately available.

The case is U.S. ex. rel. Cutler v. Cigna Corp. et al., case number 
7:17-cv-07515, in the U.S. District Court for the Southern District of New York.

--Editing by Jill Coffey.


Download Case Documents Here

Tuesday, August 4, 2020

Congress Considers Timeline as Accelerated and Advance Payment Recoupment Looms

Monday, August 3, 2020

To provide additional financial support for Medicare providers responding to COVID-19, and pursuant in part to CARES Act requirements, the Centers for Medicare & Medicaid Services (CMS) expanded the Accelerated and Advance Payment Programs for providers and suppliers. CMS used existing rules that allow providers and suppliers to receive an advance on Medicare claims payments if they have experienced financial difficulties due to a delay in payments or in other exceptional situations.

Now, approximately four months after the first accelerated and advance payments were distributed, early applicants are approaching the date when Medicare will begin recouping payments through zeroed out claims, absent congressional action. These repayments are coming due at a time when providers still face critical financial challenges and reduced patient volume due to the pandemic.

Accelerating Medicare Payments to Providers

COVID-19 placed significant financial pressure on hospitals, physician practices and other providers and suppliers. Some were overwhelmed by a dramatic increase in COVID-19 patients, while others sat empty as non-emergency procedures were cancelled and patients under stay-home orders delayed care. CMS used the Accelerated and Advance Payment Programs to provide cash flow to affected providers. Unlike the Provider Relief Fund, the Accelerated and Advance Payment Programs provide loans that must be repaid.

For providers and suppliers who participate in the Accelerated and Advance Payment programs, claims recoupment via withheld claims begins 120 days after issuance of the payment. For suppliers, repayment of the full balance is due 210 days after the issuance of the payment; most hospitals have a full year to repay the balance. For both the Accelerated and the Advanced Payment Programs, unpaid balances due at the end of the repayment period are subject to the private consumer rate of interest rate, currently 9.5%.

CMS paused both programs on April 26, 2020, citing other funds available to the provider community.

Payments Come Due for Hospitals, Physicians and Suppliers. Physician practices and other suppliers had 120 days from the date CMS issued their payment. At least one MAC has indicated recoupment began July 27, 2020.

Legislation Could Extend Repayment Timeline

Given the state of COVID-19 recovery, it seems likely that Congress will extend the recoupment period for loan recipients. In May 2020, the US House of Representatives passed the Health Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which would extend the timeline for recoupment and repayment of the loans. On July 27, 2020, Senate Republicans introduced the Health Economic Assistance, Liability Protection and Schools (HEALS) Act, which also would extend the repayment and recoupment terms, although for a shorter period. HEROES would take the additional steps of reducing the interest rate and reducing the amount of clHT NNaims recoupment. HEALS does not include parallel proposals affecting interest rates or recoupment amounts.

Some provider groups are pursuing legislation that would forgive these loans altogether. H.R.7292, introduced in June, would, among other things, forgive debts arising under these programs for providers, suppliers and physicians meeting certain criteria and conditions. This bill has over 74 cosponsors as of July 31st, and support from both Republican and Democratic Representatives. Senate Democrats introduced a version of forgiveness in May. S. 3750 would grant CMS the authority to waive repayment for Accelerated and Advance payments for providers facing significant hardship for at least two years. Full forgiveness has not appeared in either HEROES or HEALS, making it a long-shot to be included in a negotiated compromise this month.

Leadership from both parties continues to work toward a deal on broad stimulus and relief legislation that also would address this program. Final agreement is anticipated sometime in the next few weeks, but it is unlikely that an agreement will be finalized before some providers’ and suppliers’ repayment periods commence.

How Will the MACs Respond? Practical Considerations for Providers

Seven MACs are tasked with administering accelerated and advance payments and taking initial actions to recoup Medicare funds. In general, CMS instructs MACs on how to adhere to the agency’s guidance and regulatory requirements. MACs therefore may need clear instructions from CMS to alter their recoupment process in response to any legislative change. It is unlikely that CMS will take any such action in the absence of legislation. Providers and suppliers that obtained advance or accelerated payments therefore may experience a few bumpy weeks as MACs implement a large-scale recoupment program under shifting instructions from CMS, and as CMS awaits final stimulus legislation. Early recipients of advance or accelerated payments may be subject to claims reductions that start and stop as a result of the shifting policy environment and current lack of clarity for MACs.

Providers and suppliers may wish to take steps now to advocate for a smoother approach and to prepare operationally for a period of uncertainty. Providers and suppliers can communicate with their MACs to request information on how they will handle recoupment of advance and accelerated payments, and to request a brief grace period to account for the legislative process on Capitol Hill. Providers and suppliers also should continue to share feedback with CMS and the MACs regarding the internal disruption that could result from recoupment processes being started and stopped, and to urge CMS and the MACs to hold off on recouping funds until the timeline is finalized legislatively.

Finally, providers and suppliers can continue to put pressure on Congress to resolve this matter legislatively as quickly as possible. In the meantime, providers should take operational steps to prepare for recoupment to begin.