Biden administration proposes crackdown on scam Medicare ads

https://apnews.com/article/health-medicare-government-and-politics-19ce28f3a5919d27cbff3dcb6d19c6e7

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I saw your post with the remote CVS work job…. here’s what I have to say. I didn’t want to post it publicly:
You know how they prepared? They launched the “Access Store” function with absolutely no standards (no one required to help anyone in particular) and THEN a week later (this past Monday) we got calls at ALL the high volume stores that all RPh overlap is being diminished/removed come 2023. So it really doesn’t matter. QP still rises, there’s no extra bodies to answer the phone. We have no idea how to navigate this. I cried when I had to make my new schedule because the loss of hours squashed my work/life balance even more. Less days off or work more 14 hour shifts to have a day of freedom. And the quality of life at work still seems to get worse😔😭

If your are looking for a new pharmacy…. try a independent pharmacy where you will be dealing with the Pharmacist/owner  here is a link to find one by zip code

https://ncpa.org/pharmacy-locator

 

 

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Perhaps Congress is part of this long game. In 2000, Congress passed the Decade of Pain Law… where practitioners were ENCOURAGED to treat pain. The Joint Commission came up with the “Fifth Vital Sign” and made it a MAJOR STANDARD for hospitals and others credentialed by the JC to meet. When the bill expired, it was not renewed and the Party that was in the majority when it was  initially passed was not in the majority when it could have been renewed.  I think that there was a fair amount of careless prescribing C-III opiates and probably a large amount of careless refilling of those same Rxs.

If the insurance companies helped the DEA, I have always thought it was strange that Congress has been claiming that they want to get prescription prices down and Congress has been going after the Pharmaceutical industry when it is common knowledge that the PBM industry gets untold number of tens or hundreds of millions of dollars from kickback/discount/rebates for meds the PBM pays for from individual pharmas.  Currently the top 5 PBM’s are owned by INSURANCE COMPANIES.  A lot of bilateral “back scratching” between DEA/Congress/insurance companies ?

How many of the Federal judges are in lock-step with the DEA ?  The J&J lawsuit being sued by numerous cities/counties/states, etc for being a public nuisance for being the wholesaler of raw opiate powder to the pharma industry.  The Federal Judge determined that the case was going to be a BENCH TRIAL… the Judge was going to be Judge, jury and executioner. Totally unexpectedly J&J was found guilty and fined 572 million dollars.

Recently Walgreen, CVS, Walmart settled a lawsuit over them being guilty of contributing to the opiate crisis for just 13 billion dollars

A federal judge in August ruled CVS, Walgreens and Walmart must pay a combined $650.6 million to two Ohio counties for damages related to the opioid crisis.

Teva Pharmaceutical Industries in July announced a $4.35 billion proposed nationwide settlement

Purdue Pharma and the Sackler families in March announced a settlement with a group of states that would require the Sacklers to pay out as much as $6 billion

Kroger $85 million settlement of all opioid litigation claims with the State of New Mexico.  Kroger has two active matters pending in West Virginia and Texas scheduled for trial in 2023 and 2024, respectively.

Judicial system: When the facts don’t support the charges… you just fabricate the facts ?

Pieces of the puzzle on how the DEA really functions

There was a recent prescriber being in federal court and the federal judge rejected the defendant’s 12 experts lined up to testify for him… and the defense was not told until a day or two before the trial. The only “expert” that was allowed to testify in this trial was hired by the prosecutor and was known as a frequently used – well paid – expert for the government and reportedly has no real expertise in pain management.

MARC MOORE: THE DIRTY COP OF MANTIS, IN THE TRIAL OF LESLY POMPY, MD. (MICHIGAN)  this trial is, which currently going on…it has been reported that the Judge will  not consider the recent SCOTUS Ruan/Kahn (9-0 vote) which basically told the DEA that they could not objective criteria in judging a prescriber in treating a pt for subjective diseases.

I have heard numerous attorneys state that when someone is taken to federal court … 90%+ are found guilty. maybe this is why all these corporations just PAY UP.  Odds are they are going to be found guilty and by agreeing to PAY UP while stating that the company while not admitting to any wrong doing.

Does this suggest that all three branches of our Federal Gov and many states and their various bureaucracies are all in lock-step with the DEA’S 50 y/o agenda ?  Where else, but American, can companies and entities be sued/fined for selling a LEGAL PRODUCT ?

The DEA’s Long Game

https://www.daily-remedy.com/the-deas-long-game/

The canary in the coal mine is a metaphor alluding to the initial sign of an impending calamity.

An apt metaphor for what just transpired. Recently, the Drug Enforcement Agency (DEA) issued a public safety alert informing the public about a, “sharp increase in fake prescription pills containing Fentanyl and Meth[amphetamines]”.

The alert was the canary in the coal mine, but the impending calamity is not what we are led to believe. We knew of a rise in counterfeit prescription pills for many years. It was a rise induced directly by DEA policies inflicted upon patients.

The impending calamity is not the risks counterfeit pills pose to the public, but the legal liability the DEA faces for its failed policies.

For years, federal agencies and physician advocacy groups remained in lockstep on the causes of the opioid epidemic. Lax prescription guidelines, over prescribing by willing physicians, and the addictive nature of opioids – we heard it all.

Unfortunately, these purported causes proved erroneous at best or deliberately misrepresented at worst. And implementation of policies based on these purported causes led to a rise in suicide and clinical stigmatization among chronic pain patients and patients with substance use dependencies.

This is an atrocity the DEA bears direct responsibility for.

The DEA orchestrated a culture of fear that can be described as medical McCarthyism, in which the fear of prosecution defined the quality of care for stigmatized patients. Accusations formed the basis of convictions as we saw physicians imprisoned for providing care and patients abruptly abandoned without legal recourse.

That is until now.

The American Medical Association (AMA) recently issued a report through its newly formed Substance Use and Pain Care Task Force recommending significant policy changes it believes would more effectively address the nation’s opioid epidemic. Stopping short of outright criticizing the DEA, the report proposes policy recommendations that diametrically oppose the DEA’s approach to the epidemic.

The report is simply the latest in a long line of published studies casting doubt on long held assumptions about the opioid epidemic. We know there is no correlation between opioid-related mortality and the number of opioid prescriptions. We know abruptly discontinuing opioids leads to adverse patient outcomes. And we know forcing physicians to reduce the number of opioid prescriptions leads to a rise in counterfeit prescription opioids.

All of which makes the public health alert by the DEA even more curious.

It is absurd to believe the DEA is not aware of the clinical consequences of its failed policies. And to issue a public health alert without acknowledging the basis for such an alert is deliberately deceptive – disrespecting the lives of patients lost through these policies and conveying a lack of accountability on the part of the DEA.

But lacking accountability is different from lacking awareness. The DEA is clearly aware that its aggressive approach to criminalizing the patient encounter has led to a rise in counterfeit prescription medications and adverse patient outcomes.

In Kentucky, a federal judge deemed a pain management practice liable for the suicide of a patient unable to receive adequate pain relief, who then committed suicide as a result of the untreated pain. The judge ruled that the physicians were liable for the suicide because they inappropriately reduced the patient’s opioid prescription dosage.

A ruling that implies patients have a right to be treated for pain, which when applied broadly to all chronic pain patients would hold the DEA liable for undue harms caused to patients based on its aggressive stance on opioid prescriptions.

Something the DEA is well aware of, but seems bent on assuming no accountability for, hoping the failed policies are seen as well-intentioned errors.

But in recently uncovered reports obtained through multiple FOIA (Freedom of Information Act) requests, it appears the DEA’s aggressive stance extends beyond erroneous policies and the unintended specter of clinical fear – to something far more nefarious, far more deliberate.

For years the DEA colluded with major insurance companies to obtain data on prescribing practices for physicians who treated patients in pain with prescription opioids, contracting covert, third-party data-mining companies to troll medical records without the consent of patients or the knowledge of physicians.

In 2016, these data-mining companies modified the data analysis, changing the definition of a high risk opioid prescriber to encompass a majority of physicians who prescribed opioids. The adjustment was a blatant attempt to coordinate and expedite the indictment of physicians, and to strengthen the likelihood of convictions.

It should come as no surprise that this is when we began to see a rise in physician imprisonments and a rise in counterfeit opioids. Both of which are a direct consequence of deliberately misrepresenting the trolled medical data.

Now, years later, lacking the support of physician advocacy groups, or the protection of public perception, the DEA finds itself confronting the ugly reality of its failed policies – and the ensuing liability.

But liability comes in different forms. Liability can be characterized as a harmless mistake or as a deliberate misrepresentation. The behavior of the DEA elucidated through the FOIA documents would suggest the latter.

Yet the public health alert provides a convenient rebuttal. A plausible excuse for the DEA to claim its failed policies were an honest mistake. The DEA can now say that when it realized its policies were leading to a rise in counterfeit opioid prescriptions, it issued a public health alert, suggesting the adverse clinical outcomes – the suicides and stigmatizations – were nothing more than an unintended consequence, an honest mistake.

For the DEA to issue a public health alert for a crisis that began years ago through its own policies is certainly a curious course of action – something we rarely see from federal agencies.

But a broader analysis reveals that the timing of the alert is less curious and more strategic. A canary in the coal mine – for the impending liability the DEA will soon face.

 

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Apparently Express Scripts new business model is to reimburse pharmacy for filling prescriptions less than the cost of buying the medication from the wholesaler.  Express Scripts just signed a contract with DOD for Tricare and it has been reported that abt 15,000 pharmacies – mostly independents – decided not to sign the contract they were offered because offered reimbursement was less than the cost of purchasing the medication from the wholesaler. Express Scripts is owned by the insurance company Cigna

Kroger operates under 22 different names and 3242 total stores and 2,200 pharmacy depts.  It would appear that of the 15,000 pharmacies not signing the new Express Scripts/Tricare contract may or may not include the 2,200 Kroger pharmacies.  Tricare is the health insurance for our military and veterans.

Previously, Express Scripts has been the labeled as largest PBM in the USA

https://www.fool.com/earnings/call-transcripts/2022/12/01/kroger-kr-q3-2022-earnings-call-transcript/

Kroger Health had another successful quarter, delivering higher-than-expected sales and profitability despite cycling the impact of higher COVID vaccine revenue from a year ago. We continue to see significant growth opportunities in healthcare, and our Kroger Health team remains committed to ensuring our customers obtain medically necessary prescriptions. Recently, we announced that we are terminating our Express Scripts agreement for commercial customers as of December 31. The Express Scripts contract would have required Kroger to fill our customers’ prescriptions below our cost of operation, something we could not accept as we aim to keep our prices low for customers during this inflationary period.

We expect this contract termination will reduce sales by about $100 million in Kroger’s fiscal fourth quarter, impacting identical sales without fuel for the quarter by approximately 35 basis points. This decision is not expected to have an impact on operating profit or EPS. Included in our results for the quarter is an $85 million pre-tax charge related to the settlement of all opioid litigation claims with the State of New Mexico. This amount was excluded from our adjusted FIFO operating profit and adjusted EPS results to reflect the unique and nonrecurring nature of the charge.

This settlement is not an admission of wrongdoing or liability by Kroger, and we will continue to vigorously defend against other claims and lawsuits related to opioids. This settlement is based on a unique set of circumstances and facts related to New Mexico, and Kroger does not believe that the settlement amount or any other terms of our agreement with New Mexico can or should be extrapolated to any other opioid-related cases pending against Kroger. It is our view that this settlement is not a reliable proxy for the outcome of any other cases or the overall level of Kroger’s exposure. Currently, Kroger has two active matters pending in West Virginia and Texas scheduled for trial in 2023 and 2024, respectively.

Kroger continues to believe that the claims are without merit, and that it has strong defenses to these claims. Kroger is also differently situated from many of the other defendants in these cases. Our pharmacy operations have a much smaller footprint, both in terms of the size of the business, and market share with respect to opioids, and we are proud of the outstanding work performed by our associates in delivering critical care and services to our pharmacy customers. Turning now to alternative profit businesses, which are a fast-growing and key part of our value creation model.

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Physical and Occupational Therapy Are on the Medicare Chopping Block

https://www.medpagetoday.com/opinion/second-opinions/102198

Cuts could be devastating to patient care if Congress doesn’t take action

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U.S. opioid crackdown hampers some patients’ access to psychiatric drugs

https://www.reuters.com/business/healthcare-pharmaceuticals/us-opioid-crackdown-hits-some-patients-access-psychiatric-drugs-2022-12-12/

WASHINGTON, Dec 12 (Reuters) – A crackdown by U.S. drug wholesalers in response to the opioid crisis is preventing some pharmacists from dispensing a combination of stimulants and sedatives routinely prescribed by psychiatrists to help patients manage conditions like anxiety and ADHD.

The three main U.S. pharmaceutical wholesalers – AmerisourceBergen Corp (ABC.N), Cardinal Health Inc (CAH.N) and McKesson Corp (MCK.N) – tightened monitoring of suspicious orders from pharmacies in July as part of a $21 billion nationwide opioid settlement with attorneys general from 46 states, the District of Columbia, and five territories.

Five independent pharmacists in five different U.S. states told Reuters that in recent months they were notified by the wholesalers that they would be cut off from the distribution of all controlled substances after filling prescriptions for psychiatric drugs such as the stimulant Adderall – used to treat attention deficit hyperactivity disorder (ADHD) – and anti-anxiety drug Xanax. The pharmacists spoke on condition of anonymity for fear of harming their businesses.

These psychiatric drugs are regulated by the federal government as controlled substances that have high potential for abuse and addiction but are not opioids.

The wholesalers imposed the bans because the pharmacies had filled prescriptions written by medical practitioners who frequently prescribed controlled substances or had filled prescriptions assigning both a stimulant and a sedative to the same patient, according to interviews with the pharmacists and letters from AmerisourceBergen to one of the pharmacies, seen by Reuters.

The U.S. Drug Enforcement Administration (DEA) identifies combination prescriptions of stimulants and sedatives as a red flag in its guidance to pharmacies on illicit drug use.

Three psychiatrists interviewed by Reuters described such combination prescriptions as medically valid and dispensed routinely for years to manage comorbidities or address stimulant side-effects like insomnia. Comorbidity refers to the simultaneous presence of two or more diseases or medical conditions in a patient.

An ADHD patient taking Adderall to focus during the day may need the sedative temazepam to sleep at night, or clonazepam to treat anxiety, the psychiatrists said. ADHD and anxiety disorders are among the most common psychiatric disorders and have a 25% comorbidity rate with each other.

Matthew Goldenberg, president-elect of the Southern California Psychiatric Society, a chapter of the American Psychiatric Association, said some members had complained that pharmacies were no longer comfortable filling combination prescriptions for controlled substances because of concern they could be blacklisted.

“This is detrimental potentially to many patients who have comorbid anxieties along with ADHD, or sleep issues along with ADHD,” he told Reuters. “I think it’s a trickle-down effect from the opiates.”

The impact on independent pharmacies’ prescriptions of psychiatric drugs from the widening crackdown on opioids has not been previously reported. There are just over 19,400 independent pharmacies in the United States, representing just over one-third of all retail pharmacies, according to the National Community Pharmacists Association (NCPA).

The five pharmacists interviewed by Reuters said wholesalers’ bans on supplies of controlled substances threatened the viability of independent pharmacies while letting chains like CVS Health Corp (CVS.N) and Walgreens Boots Alliance Inc off the hook.

CVS, the biggest U.S. pharmacy chain, did not respond to requests for comment for this story. Walgreens, the largest shareholder in AmerisourceBergen, declined to comment. Reuters was unable to determine to what degree the chains have been impacted by the enhanced monitoring.

DISTRIBUTORS FACE “LEGAL, ETHICAL TIGHTROPE”

The U.S. opioid crisis has caused nearly 650,000 overdose deaths since 1999 and is continuing to worsen, according to federal government data.

Over the past two years, the three drug wholesalers agreed to a series of settlements totalling billions of dollars following accusations they fueled the opioid crisis by turning a blind eye to high-volume prescribers and “pill mills” that supplied addicts rather than patients. The companies have denied any wrongdoing.

Under pressure from regulators, lawmakers and judicial authorities, the wholesalers developed algorithms to detect suspicious prescribing patterns for opioids such as oxycodone and fentanyl, both used medically as painkillers. They said publicly that they’ve enhanced that monitoring this year.

AmerisourceBergen’s Vice President for External and Executive Communications Lauren Esposito said the company maintains a “robust” program to monitor and halt suspicious orders of all controlled substances. It is dedicated to mitigating the abuse of controlled substances without interfering in good-faith clinical decisions made by doctors, she said.

“Pharmaceutical distributors must walk a legal and ethical tightrope between providing access to necessary medications and acting to prevent diversion of controlled substances,” Esposito said in a written statement. “We continue to advocate for greater clarity and regulatory guidance on the matter.”

Cardinal Health and McKesson did not respond to requests for comment.

The SUPPORT Act of 2018, designed to tackle the opioid epidemic, required the DEA to implement a program with distributors to record suspicious orders of controlled substances and to share that information with state governments. It also mandated the DEA and the U.S. Food and Drug Administration (FDA) to provide guidance to pharmacies on suspicious orders.

The DEA, in response to Reuters’ questions, said it does not “participate in the practice of medicine” and does not determine what would constitute an “antagonistic combination” of drugs.

A spokesperson for the FDA said that in general it does not regulate the practice of medicine and cited National Institute on Drug Abuse (NIDA) guidance that stimulants should not be used with other medications unless recommended by a physician.

DEPRESSED

Daniel, a 37-year-old California-based private equity executive, said he has been forced to ration Adderall twice in the past two months because his pharmacy either asked him to delay filling a combination prescription or to fill it partially elsewhere amid concerns that the dispensary might be blacklisted by wholesalers.

Daniel, who declined to give his last name over medical privacy concerns, said his pharmacist had asked to just dispense his Klonopin, prescribed for anxiety, and for him to fill his Adderall prescription elsewhere so that the pharmacy would not get in trouble. He declined to identify the pharmacy.

“I’m the president of a company. I need to confidently make decisions, and anxiety is not something that allows that to happen,” he told Reuters.

Psychiatrists said the problem for some patients has been compounded by a nationwide shortage of Adderall in recent months due to manufacturing delays at Teva Pharmaceutical Industries Ltd (TEVA.TA), the Israel-based company that produces it. Teva said that, in addition to the production issues, there had been a “significant rise” in national prescription rates for the drug.

“If you’re on a dose of Adderall and you stop it, you can feel terrible,” said Eric Levander, a Los Angeles psychiatrist, who said at least five of his patients have been unable to fill their prescriptions at multiple pharmacies because of the crackdown.

Aside from the medical drawbacks, patients run the risk of being flagged as suspicious in state Prescription Drug Monitoring Program (PDMP) databases – which are accessible by law enforcement – for attempting to fill prescriptions in several places, he said. ‘Pharmacy shopping’, if it entails attempting to obtain a narcotic by fraudulent means, is typically a felony and can result in a heavy fines or jail time.

“I had a patient run out of his stimulant medication for a few days, and he was depressed for a week afterwards and screwed up on his exams,” Levander said.

NO REVIEWS

AmerisourceBergen had informed clients in March that changes to its Controlled Substance Monitoring Program (CSMP) would kick in from July 1 as a result of the nationwide settlement, a presentation made public by the company showed.

AmerisourceBergen predicted a higher number of orders would be flagged as suspicious. Previously, the company reviewed suspicious orders and then either approved or cancelled the shipments but it said that under the new system such orders would be canceled automatically and reported to regulators without review. AmerisourceBergen said all three wholesalers were subject to the exact same requirements.

Anne Burns, vice-president of the American Pharmacist Association (APhA), said that, while wholesalers had initially focused their monitoring on opioid orders, they have increased their scrutiny of stimulants following a rise in the illicit market for them.

Reports from pharmacies across the country suggested the focus was spreading to other controlled substances as well, she added.

“We’ve really been pushing the DEA and wholesalers … be more transparent on how these decisions are made, about what the pharmacy is able to order or not,” Burns said.

The pharmacists interviewed by Reuters said they had received no clear rules on which drug combinations are problematic nor the ratio of controlled substances as a proportion of total prescriptions deemed suspicious.

The pharmacy owners interviewed by Reuters in California, New York, Florida, Iowa and Kansas described a near-identical pattern for the three wholesalers.

Firstly, individual orders would be denied without explanation, followed by a letter from the wholesaler suspending orders of any controlled substance for a year, citing red flags like suspicious combinations of drugs or filling prescriptions from medical practitioners who prescribe too many controlled substances.

Then, pharmacies were given a window to appeal that decision but then told within a month their response was not satisfactory and the ban on orders of controlled substances would stand.

“It’s a real challenge for smaller pharmacies to defend themselves against this kind of behavior,” said Al Harris, lawyer for Ken’s Sunflower Pharmacy in Kansas.

The pharmacy sued AmerisourceBergen for breach of contract after it banned Sunflower in June from ordering controlled substances, saying it filled prescriptions written by a doctor prescribing too many controlled substances and filled too many prescriptions containing ‘antagonistic combinations’.

“My client is not diverting oxycodone under the streets,” said Harris. “He’s a small pharmacy, and they can crack down on him with nearly no financial detriment to themselves.”

AmerisourceBergen said its diversion control program applied to all orders across all companies – regardless of chain or independent affiliation.

Amazing… from the article:

The DEA, in response to Reuters’ questions, said it does not “participate in the practice of medicine” and does not determine what would constitute an “antagonistic combination” of drugs.

A spokesperson for the FDA said that in general it does not regulate the practice of medicine and cited National Institute on Drug Abuse (NIDA) guidance that stimulants should not be used with other medications unless recommended by a physician.

The pharmacists interviewed by Reuters said they had received no clear rules on which drug combinations are problematic nor the ratio of controlled substances as a proportion of total prescriptions deemed suspicious.

The SUPPORT Act of 2018, designed to tackle the opioid epidemic, required the DEA to implement a program with distributors to record suspicious orders of controlled substances and to share that information with state governments. It also mandated the DEA and the U.S. Food and Drug Administration (FDA) to provide guidance to pharmacies on suspicious orders.

The support act of 2018: 

H.R.6 – Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act

This bill was apparently introduce when the REPUBLICANS had a majority of both Houses and signed into law 10/24/2018 by President Trump.

So all of you who have called, emails, faxed, phone called members of Congress about the plight of the chronic pain community… would appear to have fallen on deft ears.  So the DEA is apparently come to the conclusion that our CONGRESS has decided that the prescribing of controlled substance is – and has been – the genesis of the hypothetical  opioid crisis. Our course, this has been the target of the DEA since they were created in 1973, so they have failed at their primary mission for nearly FIVE DECADES.  The DEA is just following one of the laws that our Congress has passed – FOUR YEARS GO !

Apparently since the SCOTUS told the DEA in a June ,2022 that: 

Supreme Court Tells Cops To Stop Playing Doctor – BUT – will they listen – or – back to business as usual ?

This is PLAN B for the DEA after the SCOTUS ruling.

The various states/counties/cities have apparently extracted enough $$$ out of the chain’s “deep pockets” …  and the abt 20,000 independent pharmacies have no “deep pockets” and it will be too costly to sue independents.

Those of you have gotten state laws passed or working on getting state laws passed to protect chronic pain community …  if drug wholesalers are going to limit sales to pharmacies – especially independents – and it seems like since the SCOTUS ruling the DEA as accelerated the raiding of office practices.

The chains pharmacies knows that the various bureaucracies will continue to come after their “deep pockets”  if they don’t cooperate in curtailing the dispensing of controlled meds.

 

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Should Doctors Warn Patients About the Downsides of Medicare Advantage Plans?

Beneficiaries may not be aware of the plans’ limited networks or prior authorization rules

https://www.medpagetoday.com/special-reports/exclusives/102143

Many doctors tell variations of this same frustrating story after every new year. A long-time patient shows up for a routine scheduled appointment with “great news.”

“Doc, I heard this terrific TV ad — even had Star Trek’s Captain Kirk — about a better Medicare plan for me. So I called the number on the screen and an agent signed me up. He said I would save tons of money! So I dropped my drug and supplemental plans, and now my prescriptions, eyeglasses, and hearing aids will all be covered!”

The doctor groans to himself. This patient doesn’t realize it, but he is no longer in Medicare. He has been enrolled in a commercial Medicare Advantage (MA) plan run by a private company with a provider network to which his long-time doctor does not belong. Or the doctor is contracted with the plan and in-network, but his practice is at capacity so he’s not accepting new enrollees. Or the waiting list is long.

Doctors are left with a choice: send the patient home without care, ask the patient for payment, or be prepared to give the service for free. “It’s very common for patients to come to my office thinking they still have Medicare when they’ve actually signed up with a Medicare Advantage plan and don’t understand that they have given away their rights to that card,” said James Grisolia, MD, a San Diego neurologist.

Doctors, especially specialists, said they have concerns about how exaggerated claims on TV ads and other marketing material mislead patients into thinking they can continue to see any doctor they had been seeing prior to their switch.

No Prior Authorization

If the doctor is not in that plan network, “they have absolutely no insurance coverage when they arrive,” Grisolia said. But even if the doctor is in the MA plan’s network, the MA plan required that the visit receive prior authorization, which wasn’t obtained.

This troublesome issue occurs more often these days as an increasing percentage of Medicare-eligible patients — now roughly 48% of 58 million beneficiaries — are enrolled in Medicare Advantage plans. Some doctors think they should go out of their way to alert their naïve patients to the downsides of these plans before they change their coverage.

“We definitely have patients who join one of these plans and then ask us afterwards about it, when it’s too late” because the enrollment deadline has passed, said David Podwall, MD, a New York neurologist who is president of the Nassau County Medical Society. “We tell them we’re not in their new plan. They have to seek new doctors.”

Texas Medical Association President Gary Floyd, MD, said that doctors in his state do reach out. They distribute information sheets listing the pros and cons. “But it’s my impression that even if the [patients] look at that, they tend to get sucked into buying the plan with the cheaper premium.”

The TV ads, he said, are “almost false advertising, because they make the plans sound like the best thing since sliced bread, that a retired person doesn’t have to pay anything. That’s great for outpatient visits when they go once or twice a year, but when they get sick and go into the hospital, they realize they don’t have coverage for that.” Generally, said Floyd, most of the doctors who take care of adults tell them that “if and when you go on Medicare, stick with the plain, regular Medicare system. Don’t take Medicare Advantage because it’s not going to give you the coverage you need if you get sick and have to be in the hospital.”

Talk With Patients

But how aggressively should the physician pursue the issue with a Medicare-eligible patient? Joan Teno, MD, an internal medicine geriatrician and researcher at Brown University in Providence, Rhode Island, has serious concerns about the power health plans have to drop doctors from their networks with a mere 30-day notice. For that reason, among many others, she believes doctors do have an ethical obligation to warn their patients, even if the patients don’t initiate the conversation.

Additionally, beneficiaries have no way to compare the quality of the plans. “Consumers want to know which plans seem to be overly aggressive in their denials and their limits on access,” she said. How often does the plan reject beneficial treatment? “This information is just not available to make a decision … Maybe the way consumers should think about this is to avoid MA plans at all costs,” she said.

Dirty Little Secret

Complicating the issue is that once enrolled in a Medicare Advantage plan for 12 months, it can be impossible to return to traditional Medicare without incurring enormous deductibles and co-pays of 20%. In addition, Medicare supplemental policies — also called Medigap plans — that pay those costs for the beneficiary can reject an applicant through underwriting questions on the basis of common pre-existing conditions. Only Maine, Massachusetts, New York, and Connecticut prohibit Medigap underwriting.

Gail Anderson, MD, a Bowie, Maryland otolaryngologist who retired earlier this year, said she knew nothing about Medicare choices while she was practicing. The office took care of all that. Now 69, she was faced with a “shock” at how difficult it was to differentiate. “We weren’t taught anything about this in medical school,” she said. And if she, a physician, had difficulty, “how can the average person understand what to do?” she asked.

She finally turned to her hospital’s former CEO, a long-time friend. “Look Gail, you don’t want a Medicare Advantage plan,” he told her. Anderson added that “he told me that with MA plans, I’d be limited to a network of doctors and you don’t get covered when you travel.”

Many physicians interviewed acknowledged that they don’t have the time to discuss the issue, nor do they really know the differences between so many Medicare plans — that it’s too complicated or “not in their lane.” And besides, they don’t have that kind of time during an office visit.

Brokers, Anderson acknowledged, may have a conflict of interest because they earn hefty commissions for selling MA plans. But she learned of a resource she didn’t know about before to whom doctors can refer their patients. The federally supported State Health Insurance Assistance Program has offices in each state specifically set up to provide seniors with unbiased, truthful guidance.

The Need for an Accurate MA Doctor Directory

Doctors feel so strongly about problems with Medicare Advantage network adequacy that during the interim American Medical Association meeting last month, members approved a resolution calling for “Uniformity and Enforcement of Medicare Advantage Plans and Regulations.”

The resolution authorizes the AMA to urge the Centers for Medicare & Medicaid Services to publish an “accurate, up-to-date list of physicians” in each plan network, and to specify whether each doctor is taking new patients. When physicians stop taking new enrollees, they would notify the directory.

“We know doctors move in and out of these plans on a daily basis,” said Jenny Boyer, MD, an Oklahoma psychiatrist who proposed the AMA resolution, which also asks for CMS to be more aggressive in holding the plans accountable for abiding by CMS standards regarding network adequacy.

Can You Still See Me?

Ted Mazer, MD, a recently retired California otolaryngologist who will soon turn 65, thinks physicians should talk with their patients about the upsides and downsides of Medicare Advantage plans — including their limited networks — compared to standard Medicare, especially if they’re about to become eligible. “Doctors can bring up the topic by saying something like, ‘by the way, you’re going to be on Medicare in a few months. Do you know which Medicare program you’re going to so we can discuss whether you can continue your care here?’ That’s advocating for the patients’ access, so why the heck not?” he said.

“They might say to their patient, ‘here’s something you need to know: If I try to refer you to a specialist, I may have a problem. So if you want Medicare Advantage, you should first check whether all the specialists that you might need to see are in your network and accepting new patients,'” he said.

Of course no patient can know what her future medical needs will be, and thus won’t always know which doctors she should check. And even if the provider is in the network, he or she may not be the following year, and the patient will have to find someone else.

NYU Langone bioethicist Arthur Caplan, PhD, said that not only can doctors talk with their patients, they should. “Doctors have a duty to inform patients to the extent they know about the upsides and downsides of Medicare Advantage, especially if their older patients are getting heavy pressure from home care and other companies to sign up.”

And if the doctors don’t know, “they ought to direct patients to elder law attorneys, whether the patients ask or not. And it’s especially true if the patient is overwhelmed and needs family or friends’ involvement. Preventing fiscal toxicity and loss of access is an important, admirable, and virtuous thing to do if providers can do so.”

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Judicial system: When the facts don’t support the charges… you just fabricate the facts ?

 

 

 

 

While letter is from 2009,  it is not that far removed from a post that I made today and the ;procedures our judicial system will go to, in order to secure a conviction. It seems that many of the major federal agencies – particularly those involving our judicial system…  their SOP doesn’t change – WIN AT ANY COST How many healthcare practitioners are behind bars, that even the truth could not set them free. I am starting to see a pattern, why 90%+ of people taken to federal court are FOUND GUILTY ?

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‘IN THE TRIAL OF LESLY POMPY, MD’ “THE STRANGE MR HOWELL” REVEALS MICHIGAN BLUE CROSS BLUE SHIELD CO-INTELL PROGRAM TO TARGET, DESTROY, GET RID OF BLACK, INDIAN, JEWISH AND ASIAN PHYSICIANS/PHARMACISTS/ DENTISTS

https://youarewithinthenorms.com/2022/12/03/in-the-trial-of-lesly-pompy-md-the-strange-mr-howell-reveals-michigan-blue-cross-blue-shield-co-intell-program-to-target-destroy-get-rid-of-black-indian-and-asian-physicians-pharmacists/?mibextid=Zxz2cZ

REPORTED

BY

http://www.youarewithinthenorms.com

NORMAN J CLEMENT RPH., DDS, NORMAN L. CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, JOSEPH SOLVO ESQ., REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., WILLIE GUINYARD BS., WALTER L. SMITH BS, MS., BRAHM FISHER ESQ., JOSEPH WEBSTER MD., ESTHER HYATT PHD., MICHELE ALEXANDER, CUDJOE WILDING BS, MICHELLE LYNN CLARK RPH., DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS

“No. 18-cr-20454” United States v. Pompy, Criminal Case No. 18-cr-20454, (E.D. Mich. Mar. 16, 2021)

BACKGROUND NOTES FROM TRIAL

 

James Stewart, aka James Howell ( Blue Cross employee), presented to the medical office of Lesly Pompy, MD., requesting to be a new patient on 1/5/2016. The receptionist told him that he needed a referral for pain management.

Stewart’s mission was simple to disrupt and destroy Lesly Pompy MD, as he had done previously to other healthcare providers of color on behalf of BCBS of Michigan.

“As an employee of Bue Cross Blue Shield of Michigan Mutual Insurance (BCBS) company, he got one of their doctors (working for them), Doctor J Alan Robertson, to refer, aka James Howell, to Pain Management. James Stewart “complained of back and nerve problems.”

Instead of dating the referral from 1/5/2016 onwards – both aka Howell and Robertson conspired to backdate the referral for 12/2015 after asking about the Blue Cross undercover investigation. Intending to trick the doctor, James Stewart, aka James Howell, lied in the referral doctor used the Blue cross to lie for MANTIS.

James Stewart got a fake Michigan driver’s license from the Secretary of State, with doctors (then prosecutor, now judge) William Paul Nichols, Marc Moore, Brenth Cathey of the Monroe City Police, and driver Blair of the Monroe County Sheriff’s office.

“No. 18-cr-20454” United States v. Pompy, Criminal Case No. 18-cr-20454, (E.D. Mich. Mar. 16, 2021)

SUMMARY TESTIMONY OF JAMES STEWART (HOWELL)

 

On December 1, 2022, and December 2, 2022, a Blue Cross Blue Shield (BCBS) Corporate and Financial Investigations Department (CFID) Investigator, James Stewart Howell, testified in Court Room 216 of Eastern District Court of Michigan under cross-examination by Ronald Chapman, Attorney for Dr. Pompy presided by Hon. Stephen Murphy stated the following:

1) He was a former police officer who was hired around or about one week after retiring by BCBS CFID;

2) He was trained in Healthcare Investigations and Undercover Operations at the Blue’s Academy, which is a BCBS training program;

3) He works as an undercover “patient” seeking drugs and pills from doctors;

4) CFID does not randomly identify doctors to investigate but targets specifically identified doctors ;

5) CFID identifies doctors to investigate through BCBS employees, law enforcement, tips from doctor’s employees, undercover agents, audits, and medical record reviews;

6) CFID also identifies doctors through data mining, where they are compared against their peers;

7) That Mr. Howell was involved in hundreds of investigations of doctors (mostly of color);

8) As undercover, Mr. Howell was disguised as a patient in 30-40 investigations to get a look inside a doctor’s office and analyze the time a doctor would spend with patients and the number of employees;

9) Obtained fake driver’s license from the Secretary of State of Michigan and Michigan State Police;

10) Obtained fake insurance cards from BCBS;

11) Obtained a fake referral from a cooperating doctor who routinely works with BCBS CFID and writes fake referrals and fake prescriptions for BCBS undercover operations;

12) Makes video recordings of patients in hospitals and doctors’ offices with covert cameras hidden inside a coffee mug;

AUSA WAYNE F. PRATT

“No. 18-cr-20454” United States v. Pompy, Criminal Case No. 18-cr-20454, (E.D. Mich. Mar. 16, 2021)

13) Makes sure that targeted doctors comply with contracts with their patients;

14) Present as a fake undercover patient with fake medical diseases and symptoms;

15) Admitted to lying to obtain prescription controlled substance medications only from minority physicians or people of color;

17) Got a BCBS doctor (J Alan Robertson, MD) to fabricate a false imaging study;

18) Admitted to doing joint operations with Michigan State Police;

19) Targeted doctors who prescribe Subsys because it is an expensive drug with a potential for abuse;

20) Investigates pharmaceutical representatives at doctors’ offices to see if influences them a pharmaceutical representative influences them to prescribe certain medications;

21) Attempts to develop a false persona of drug-seeking patients;

22) Co-ordinate BCBS data mining with medical records obtained from a doctor’s office;

23) Admitted to not seeking to obtain medical records to avoid tipping the doctors off;

24) Admitted to backdating fake medical records and committing felonies without authorization as a private company;

25) Admitted to creating false Prescription Drug Monitoring Program Reports.   

GOLLUM

“No. 18-cr-20454” United States v. Pompy, Criminal Case No. 18-cr-20454, (E.D. Mich. Mar. 16, 2021)

JUDICIAL MISCONDUCT

 

All of this illegal activity appears to be conducted under the supervision of United States Attorney Wayne F. Pratt (to win at all cost) and a cadre of COINTELL cohorts who have been named in several lawsuits by patients of Lesly Pompy MD.

Including former prosecutors, judges, and police, all working hand in hand with Blue Cross Blue Shield of Michigan’s corrupt activities targetting healthcare providers of color. As one patient Lisa Shanteau Kohlman who flipped on prosecutor Wayne F. Pratt’s last week (12/01/22) testimony, stated:

“I just want to tell all of you that the prosecutor brought me in as a witness today in court. I want you all to know it didn’t turn out well for them; I was team Pompy, so much so, He & I cried while I was on the stand. My quality of life today is 20%; when he was in my life, I was damned near pain-free. I love that man, and when I left that stand, we looked at each other and lipped, I LOVE YOUthey brought the wrong girl to their side. Pompy was my God for 13 yrs. And I need him back desperately.“

“No. 18-cr-20454” United States v. Pompy, Criminal Case No. 18-cr-20454, (E.D. Mich. Mar. 16, 2021)

US District Court for the Eastern District of Michigan

MICHIGAN CASE 2:2019cv10639

PLAINTIFF:

Tammy Clark for Richard Johnson

DEFENDANTS:

Michael J St John, Michigan Department of Licensing and Regulatory Affairs, William McMullen, Michigan State Police, Jessica Chaffin, Brian Zazadny, Blue Cross Complete of Michigan, Catherine Waskiewicz, Monroe County, Jeffrey Yorkey, Mike Guzowski, Mike Merkle, Diane Silas, Blue Care Network of Michigan, Vaughn Hafner, Attorney General of the United States, Daniel White, jennifer Fitzgerald, Timothy Gates, Bill Schuette, Jack Vitale, Detective Robert Blair, Christine Hicks, William Paul Nichols, Detective John Lasota, Monroe City Police Department, Bluecaid of Michigan, Adam Zimmerman, Sarah Buciak, Officer Shawn Kotch, Matthew Schneider, Scott Beard, Diane Young, William Chamulak, John Doe, City of Monroe and Police Vice Unit, FNU Sproul, Carl Christensen, MD, Monroe Police Department, Blue Cross Blue Shield Association, I-Patient Care, Inc., Bureau of LIcensing and regulation, Donald Brady, James Stewart aka James Howell, Monroe County Circuit Court, Tom Farrell, DEtective Mike Mclain, Michael G Roehrig, Aaron Oetjens, Administrative Hearing System, Blue Cross Blue Shield of Michigan Foundation, Assistant United States Attorney, Dale Malone, Timothy C Erickson, Leon Pedell, MD, Derek Lindsay, US Attorney’s Office (DEA), Wayne F. Pratt, Detective Sean Street, Christensen Recovery Systems, Judge John J. Mulroney, MANTIS, Brandy R. McMillion, Haley Winans, Brian Bishop, Blue Cross Blue Shield of Michigan, Charles F. McCormick, Michigan Automated Prescription System, Jim Gallagher, Allison Arnold, MD J. Alan Robertson, Alan Robertson, Detective Brent Cathey, Tina Todd, Monroe County Sheriff’s Department, City of Monroe, Chris Miller and Marc Moore.

DONATE LEGAL DEFENSE

OR SEND

$10, $15, $20, $25,$50, $75, 175, $500. OR MORE TO CASH APP:$docnorm

ZELLE 3135103378 or Donate to the “Pharmacist For Healthcare Legal Defense Fund,”

 

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I heard it through the GRAPEVINE

Since I started my blog in 2012, I have tried to keep my message rather consistent. I try to educate and motivate the chronic pain pt in how to advocate for themselves.  There is so many chronic painer and so few advocates.  I try to keep the old proverb in mind “..Give a guy a fish, and he will be fed for a day. “Teach him to fish, and you will feed him for a lifetime…”   In all reality,  there are probably more new chronic pain pts created everyday than the existing number of advocates could attempt to help get pain pts proper pain management.  Not to mention that I don’t believe that there is any non-profit that has the financial resources to fund advocates doing in person advocating. There is some rumors out there that some advocates are charging for advocating for individual chronic pain pts.  Charging pts is something that I have NEVER DONE. It is claimed that 80% of chronic painer’s families are struggling financially. Many chronic painers have told me that my advice has helped them self advocate and they have been able to improve their pain management.  Going forward… I am going to ASK of people that want my advice to make a contribution to one of the four national charities listed below, these are all about THE KIDS… and charities we support. If my advice has helped you and you are financially struggling, don’t worry. If one of the charities listed below gets $5 +… that is great .. Maybe in some small way, my advice can help more than just one person/family. 

https://www.stjude.org/ St. Jude Children’s Research Hospital – deals with kids dealing with cancer and/or life threatening health issues

https://lovetotherescue.org/ Shriners Hospital – deals with kids, born with “broken bodies” and birth defects

https://rmhc-kentuckiana.org/ Ronald Mc Donald House – this is near us and just a few blocks from a very large regional pediatric hospital ,3 other major hospitals within blocks, one being a teaching hospital and having the only LEVEL ONE TRAUMA CENTERS for 100 miles and part of a medical university and  helps provide housing for families with kids in the hospital

https://t2t.org/ Tunnel to Towers Foundation – helps get handicapable housing for veterans, first responders with “broken bodies” , families with spouse/parent killed in the line of duty and Gold Star Families

I have concerns about advocates that contradict themselves, and below is an example that was brought to my attention. This advocate warns people in the first video NOT TO SHARE PERSONAL INFORMATION TO ANYONE and in the second video the advocate, is ASKING FOR A LOT OF PERSONAL INFORMATION sent directly to them.  A lot of the information being asked for is considered PERSONAL HEALTH INFORMATION that is normally covered by HIPAA.  This information could be valuable to some entities who would wish to purchase it.

My policy is when I see that someone or entity is trying to gather information on pts for some study, legal action or media story.  I share the contact information of that person/entity that is wishing to amass this information via my blog and other internet websites, any pts can reach out and talk to those wanting that information.  Of course, since I am a healthcare professional, I have to be concerned about protecting a pt’s personal health information from getting into hands of someone/entity that will do who knows what with the pt’s personal health information.  I guess that some person/entity collecting personal health information and is not a healthcare professional, probably has no responsibility nor liability in protecting that personal health information from being shared or sold to other to use in whatever manner they wish.

Some people may be more interested in monetizing – making money – off of collecting and selling your personal information

 

 

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