Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Department of Justice

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

October 18, 2018 - BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of Justice (DOJ). The District Court for the Eastern District of Tennessee unsealed a 32-count indictment that alleges four individuals and seven healthcare companies attempted to commit...


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$36.9M in Medicare Fraud Leads to Federal Convictions, Sentencing

by Thomas Beaton

New high-profile Medicare fraud cases have led to convictions and lengthy prison sentences for providers that attempted to defraud Medicare of $36.9 million. Federal agencies including HHS, the FBI, the Department of Justice (DoJ), and...

CVS-Aetna Merger Gets DOJ Nod as Aetna Sheds Medicare Part D

by Thomas Beaton

The Department of Justice (DOJ) has announced that it will approve the proposed merger between CVS and Aetna as soon as Aetna completes the divestiture of its Medicare Part D business line.   Two weeks ago, Aetna initiated the sale...

Aetna Sells Portion of Medicare Business to Fast-Track CVS-Aetna

by Thomas Beaton

Aetna has sold its Medicare Part D prescription plan business of 2.2 million beneficiaries to WellCare in an attempt to increase the likelihood of the CVS-Aetna merger closing before year’s end. In SEC filings, Aetna explained that...

Payers Sue to Collect 2017 Cost Sharing Reduction Payments

by Thomas Beaton

Payer organizations are exercising their right to use the court system to collect cost sharing reduction (CSR) payments that were not provided in the last quarter of 2017. A number of lawsuits are challenging the government’s...

GOP Senators Propose to Reinforce Pre-Existing Condition Protections

by Thomas Beaton

Half a dozen Republican Senators have introduced a bill that would ensure the Affordable Care Act’s pre-existing condition protections would remain a federal law despite upcoming legal challenges. The Ensuring Coverage for Patients...

DOJ Nabs 601 Defendants in Biggest Healthcare Fraud Takedown Yet

by Thomas Beaton

HHS Secretary Alex Azar and Attorney General Jeff Sessions have announced the largest healthcare fraud takedown yet after HHS, the Department of Justice (DOJ), and other law enforcement agencies charged 601 healthcare professionals for $2...

Humana, Roche Diagnostics Face $45M Federal Kickback Lawsuit

by Thomas Beaton

Humana and Roche Diagnostics will face a $45 million federal kickback lawsuit after a whistleblower filed a False Claims Act violation, which alleges Roche tried to entice Humana financially to secure access to the payer’s business...

Department of Justice Argues Against ACA Essential Health Benefits

by Thomas Beaton

The Department of Justice (DoJ) has argued against the Affordable Care Act’s essential health benefits (EHBs) and the law’s individual mandate by supporting a lawsuit that argues the constitutionality of both laws,...

Cigna Files with SEC to Begin $67B Express Scripts Acquisition

by Thomas Beaton

Cigna has submitted a filing to the Securities and Exchange Commission (SEC) to complete a $67 billion acquisition of the pharmacy benefit manager (PBM) Express Scripts. The payer filed the merger agreement under a temporary parent...

Former CMS Employee Found Guilty in Insider Trading Scheme

by Thomas Beaton

A former CMS employee leaked high-level information related to the agency’s rulemaking decisions and changes in provider reimbursement as part of an insider trading scheme, according to a guilty verdict in the Southern District of...

DoJ Settles $27.68M in Medicare Fraud, False Claims Act Violations

by Thomas Beaton

The Department of Justice continues its crackdown on Medicare fraud by settling various criminal cases related to $27.68 million of False Claims Act violations. Provider settlements remain the primary medium for healthcare fraud...

DoJ Charges 412 in Medicare Fraud Schemes Totaling $1.3B

by Thomas Beaton

The Department of Justice (DoJ) announced the largest ever healthcare enforcement action in the history of the federal agency took place when the Medicare Fraud Strike Force (MFSF) charged 412 defendants for Medicare fraud losses totaling...

DOJ Sues UnitedHealth over Alleged $1B Medicare Fraud

by Jesse Migneault

The Department of Justice is suing UnitedHealth  for alleged Medicare Advantage fraud in a civil case.  The complaint, filed in the Western District court, is “for monies unlawfully obtained or retained from the insurers...

Anthem Pursues Cigna Merger Up to the Supreme Court

by Jesse Migneault

Just seven days after a court upheld the initial ruling which blocked Anthem’s acquisition of Cigna, the nation’s second largest insurer is not giving up.   Anthem has confirmed that it is filing a writ of...

Will Divestitures Preserve the Health Insurance Mergers?

by Vera Gruessner

As previously reported, the insurance companies Aetna and Humana are attempting to preserve their health insurance merger by divesting millions of dollars in assets in order to satisfy the concerns of the Department of Justice. David...

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