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Justice Department accuses Anthem of Medicare fraud

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A lawsuit filed by the Department of Justice against Anthem accuses the insurer of collection million of dollars by failing to delete inaccurate diagnosis codes for Medicare Advantage patients. The suit was filed on Friday by Geoffrey Berman, United States Attorney for the Southern District of New York.

The case alleges that Anthem falsely certified the accuracy of the diagnostic data it sent to the Centers for Medicare and Medicaid Services, causing CMS to calculate risk-adjustment payments to the insurer based on inflated diagnosis information. For example, Anthem submitted an ICD-9 diagnosis code for active lung cancer for one patient, but its chart review program did not substantiate the diagnosis, according to court documents.

Anthem implemented a retrospective chart review program using a vendor called Medi-Connect, according to the lawsuit. The insurer reportedly paid Medi-Connect to connect medical records from healthcare providers and review them to identify diagnostic codes supported by the medical records.

According to court documents, from 2014 to 2018, Anthem allegedly used the chart review program to find additional codes to submit to CMS while failing to identify and delete inaccurate codes. The chart review program brought in more than $100 million in revenue per year for Anthem, according to the complaint.

“The integrity of Medicare’s payment system is critical to our healthcare,” Berman said in a news release. “This office is dedicated to vigorously using all of the legal tools available, including the False Claims Act, to ensure the integrity of Medicare payments.  The case against Anthem today is an illustration of that commitment.”

Anthem said it was confident its health plans complied with regulations, and that it would vigorously defend its risk adjustment practices.

“This litigation is the latest in a series of investigations on Medicare Advantage plans. The government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare, and those inconsistent standards violate the law,” the company wrote in an emailed statement. “The suit is another in a pattern that attempts to hold Anthem and other plans to a standard on risk adjustment practices, without providing clear guidance. Where regulations have not been clear, Anthem has been transparent with CMS about its business practices and good faith efforts to comply with program rules.”

Photo credit: zimmytws, Getty Images

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Foundation Medicine signs $111M contract with Department of Veterans Affairs

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genomics

One of the largest healthcare systems in the country will incorporate genomic sequencing for its cancer patients.

Cambridge, Massachusetts-based next-generation sequencing firm Foundation Medicine – now owned by Swiss drugmaker Roche – said Tuesday that it had signed a contract with the Department of Veterans Affairs’ National Precision Oncology Program to provide comprehensive genomic profiling for veterans with advanced cancers. The contract will cover all the company’s tests, including FoundationOne CDx, FoundationOne Liquid and FoundationOne Heme.

The company, which appointed Cindy Perettie as its CEO last month, launched the liquid biopsy test in September.

The five-year contract is worth about $111 million and is IDIQ, which stands for “indefinite delivery/indefinite quantity” and means it provides for an indefinite amount of products and services within the time frame, with the company being paid on a per-test basis. In a phone interview, Tom Civik, Foundation Medicine’s chief commercial officer, said that in the next couple of weeks, it will meet with the VA to work through the logistics and ensure that it can meet the department’s needs.

The $111 million amount is based on the estimate that there will be 8,000 tests performed over the course of those five years. Civik said he expects that the needs of the veteran community are likely consistent overall with those seen across the US, with similar insights to be gleaned from the technology. However, there may be some differences such as the ages of patients and the types of cancers they might have. “It’s a great opportunity for us,” he said. “Most importantly for us, we’re honored and humbled to serve veterans with this technology in the time they need it the most.”

One potential opportunity that the partnership affords if for medical research. Most of the VA hospitals, Civik said, are either attached or close to teaching institutions where large clinical trials take place. Consequently, in addition to an interest in using its NGS tests to match patients to targeted therapies, there is also a strong interest in matching them to clinical trials. “Clinical trials and advancing knowledge around this patient population and genome profiling is something we’re extraordinarily interested in,” he said.

Photo: jxfzsy, Getty Images

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