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Specifically, consideration is given to: (1) the potential for increased charges or reported costs to a FHCP; (2) the possible encouragement of overutilization; (3) the potential for adversely affecting competition by freezing competing suppliers out of the marketplace; and (4) patient freedom of choice.
* The mere potential for increased costs to, or a payment to be made by, an FHCP may be enough to violate the law; no actual payout by an FHCP is necessary as long as the challenged remuneration is for an item or service that could be paid for by an FHCP; (80) and
Before passage of MMA, the OIG had very little interest in PAPs that provided free drugs directly to uninsured patients because there were no FHCP dollars involved.
02-1, we approved an arrangement for drug manufacturers to pool contributions in an independent foundation that awards grants based on need, without reference to any specific contributing drug manufacturer"); and (2) manufacturer PAPs in which companies provide free drugs to financially needy beneficiaries, as long as no FHCP is billed for the drugs.
The term "Federal Health Care Program" ("FHCP") is defined as: (1) any plan or program, other than the Federal Employees Health Benefits Program, that provides health benefits either directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States government (e.g., Medicare, the Civilian Health and Medical Program of the Uniformed Services ("CHAMPUS"), Department of Veterans Affairs health programs); and (2) any "State Health Care Program," defined as a state program funded under United States Code Title 42, Chapter 7, Subchapter XIX (i.e., Medicaid), Subchapter V (i.e., Maternal and Child Health), or Subchapter XX (Social Services Block Grants).
All medical services were provided to FHK enrollees through FHCP. FHCP contractually agreed to perform all provider recruitment and network maintenance necessary to ensure adequate access and service provision.
According to FHCP, participating physicians were told by the plan to expect that FHK enrollees would be like Medicaid patients in their utilization of care.
The FHCP submitted a comprehensive benefit package priced at $58.98 per enrollee per month, as noted earlier.
This disproportionate share of ER utilization early in enrollment might imply that pent-up demand exists, but is being served in ERs, rather than in the offices of FHCP physicians.
As part of the risk of covering this population, FHKC and FHCP expected utilization to occur in particularly inefficient ways.
These data suggest the possibility that FHK participants were substituting visits to their primary care physician or the FHCP walk-in clinic for more costly ER care, much as FHCP sought.
FHCP attributes the decline in ER use and the increase in use of primary care physicians to three features of the program.
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