January 2019 Volume 21 Issue 1
Providing Current Information on

Health Insurance Industry Issues and Legislation

DOJ Joins Medicare Advantage DRG Fraud Lawsuit
The Department of Justice has announced it is joining a lawsuit accusing Sutter
Health of submitting unsupported diagnostic codes to Medicare Advantage plans
to generate inflated payments. The whistleblower suit, filed by a former employee
of the Palo Alto Medical Foundation (PAMF), accuses Sutter and PAMF of knowingly
submitting false health status information.
DRG Validation Available for Hospital Claims
Miscoding happens and can be very costly. The DRGs on hospital inpatient claims
are not always consistent with the procedure and diagnostic codes on those claims.
Sometimes, the procedure and diagnostic codes, and the resulting DRGs, are not
supported by the medical records. One estimate is that the DRGS are incorrect on
as many as 1 in 5 hospital claims. The result can be overpayments of thousands
or, in some cases, tens of thousands of dollars. H.H.C. Group offers DRG Validation
services to identify and correct these potentially costly errors.
Huge Generic Drug Price Fixing Scheme Uncovered
A complaint filed in U.S. District Court by Attorneys General in 20 states alleges
to have "uncovered evidence of a broad, well-coordinated and long-running series of
schemes." The suit accuses 6 major generic drug manufacturers of fixing the price
of glyburide, an oral diabetes drug which helps control blood sugar. Generic drugs
now account for 80% of prescriptions written in the U.S. and their prices have been
skyrocketing with one drug's price increasing an incredible 8,281%.
Medical Advances for Employers to Watch in 2019
New medical innovations are coming to the healthcare marketplace almost every day.
From easy digital tools to major medical advances, they are transforming the healthcare
industry. Some of the new medical treatments and advances present a double-edged
sword for employers. They mean more claims to covers with higher potential costs but
also potentially more efficient and effective treatments which can lower total costs.
Three Star Preferred Provider Program Additions
Caris MPI Inc.
Dallas, TX 75284

Eyecare Associates
Bloomington, IN 61701

Dr. Arif Iqbal
Houston, RX 77068

Advance Wound Care and Limb
Preservation, LLC
Mobile, AL 36608