Archive for year: 2018

By César Rojas Ángel

Sears cerrará 46 tiendas este mes y 142 más antes de terminar el año pero mantendrá una base de las 700 tiendas más rentables y presentará un plan para saldar sus deudas.

El 15 de octubre Sears Holdings Corp presentó una solicitud a un juez de Nueva York para acoger las firmas padres de la compañía, Roebuck and Co y Kmart Corp. bajo el capítulo 11 del Código de Bancarrota de EstadosUnidos. Una medida desesperada luego de no obtener ganancias desde 2011.

En un comunicado, la cadena estadounidense anunció una serie de acciones para lograr una línea de liquidez de 300 millones de dólares, continuar racionalizando su modelo operativo y “crecer rentablemente a largo plazo”.

El plan, además de contemplar los cierres de algunas tiendas e incluir nuevos préstamos, está marcado por la renuncia de Eddie Lampert como director, aunque seguirá siendo miembro de la junta directiva.

Eddie Lampert, el billonario que acusan de llevar a Sears a la crisis

Para muchos analistas, los movimientos financieros de Edward Lampert son parte de la causa de la bancarrota. El multimillonario adquirió la compañíaen 2005 por 11 mil millones de dólares y actualmente se calcula que él y sufondo de cobertura ESL Investments posee el 50% de las acciones de Sears y es su más grande acreedor.

La compañía vendió 235 de sus mejores tiendas por 2,7 miles de millones de dólares a la firma Seitage Growth Properties, también de Lampert. El billonario también se convirtióen el mayor accionista de la marca de ropa Land’s End Inc., cuandoesta se separó de Sears en 2014.

Estos movimientos podrían hacer parte de la investigación ahora que los acreedores presentaron el caso por bancarrota en la corte.

“Cuando vas a bancarrota, empiezas a vivir en una pecera y cada transacción será vista y examinada”, le dijo a Reuters Corali Lopez-Castro, Managing Partner de la firma de abogados Kozyak Tropin & Throckmorton.

Otros intentos por evitar esta situación fueron la venta de Craftsman, una marca de herramientas, a Stanley Black & Decker por 900 millones de dólares. Y también hubo un acuerdo para vender la marca de electrodomésticos Kenmore a Amazon.com.

Sears: el gigante de las tiendas por departamentos que perdió estatura

Para muchos, Sears fue una versión temprana de Amazon. Desde su fundación en 1880, la compañía empezó a distribuir catálogos y a entregar productos por correo. Su crecimiento fue tal que cuando construyeron la Torre Sears en 1976 se instaló como el edificio más alto del mundo.

De los cerca de 100 mil empleados, ahora quedan alrededor de 70 mil y de las 3500 tiendas que alcanzó a contaren el pasado quedarán 700 al final del año.

Las acciones de la compañíabajaron un 20% a 32 centavos. Lo cual capitaliza a Sears en 32 millones de dólares.

En estos casos, los accionistas generalmente pierden todo o la mayor parte de sus inversiones cuando una compañía aplica a la bancarrota. La habilidad de Sears para evitar el cierre definitivo dependerá de la disposición de los acreedores y proveedores para mantener la compañía a flote.

Las ventas en la próxima temporada navideña serán claves para determinar el futuro de Sears.

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By Karen Appold

A federal judge sided with UnitedHealthcare and other payers in a case that challenged an Overpayment Rule adopted by CMS in 2014.

CMS implemented the rule to comply with the ACA, which introduced a new mandate that if a Medicare Advantage insurer identified an overpayment it was required to report the overpayment and return the overpayment amount to CMS within 60 days, says Richard L. Trembowicz, JD, associate principal, ECG Management Consultants, a healthcare consulting firm.

The Overpayment Rule defined an overpayment as a payment resulting from any diagnostic code that was inadequately documented in a patient’s medical chart and which a Medicare Advantage insurer should have determined through reasonable diligence that the claimed code was undocumented and, therefore, the insurer had received an overpayment.

“In effect, the 2014 Overpayment Rule required that all diagnoses submitted to support risk adjustment payments be 100% correct on review, and that reasonable diligence would be required to avoid a False Claims Act (FCA) charge if an overpayment was not returned within 60 days,” Trembowicz says. “Most insurers conduct a representative sample of medical chart documentation and coding practices to satisfy the reasonable diligence standard, but they do not review 100% of patient charts, creating a factual conundrum of how much of a proactive review is reasonable.”

Here are three other things MCOs should know about the September 7 ruling.

1. The court addressed various reasons for finding that the Overpayment Rule was inequitable. The court concluded that CMS was imposing stricter requirements for reporting and identifying overpayments on Medicare Advantage payers than traditional Medicare regulations.

The Social Security Act requires “actuarial equivalence” between CMS payments made to Medicare Advantage payers and those made under traditional Medicare. The court stated that although payments for services under traditional Medicare and Medicare Advantage are set by the same methodology, the Overpayment Rule “systemically devalues payments” to Medicare Advantage payers, says Maria Garcia, JD, of counsel, KozyakTropin& Throckmorton.

The court found that CMS doesn’t have the legislative authority to apply more stringent standards to impose FCA consequences through regulations. The court reached this conclusion because the FCA imposes liability for knowingly submitting false claims for payment to the government, while the Overpayment Rule states that only reasonable diligence must be used to determine whether an overpayment from CMS has been received and therefore has to be returned, Garcia says.

“Simply put, the court found that the FCA’s and Overpayment Rule’s standards were inconsistent, yet imposed the same severity of penalties,” Garcia says. “The court agreed with UnitedHealthcare that Congress intended the FCA to punish and deter fraud, and to not punish an honest mistake or an incorrect claim submitted through mere negligence.”

2.  The ruling is a significant win for insurance companies. At this point, the ruling likely nullifies the obligations imposed on Medicare Advantage payers to report overpayments as delineated in the Overpayment Rule, Garcia says. Furthermore, insurance companies may face lower costs when reporting to CMS.

Although this ruling only addressed Medicare Advantage plans, which are covered under Medicare Part C, it may also effect Medicare Part A and Medicare Part B overpayment rules and their validity because of the various similarities between the overpayment reporting requirements applicable to these other sections of the Social Security Act. “Medicare Advantage payers should be ready to assess potential changes and review internal procedures to comply with the developing CMS reporting requirements for possible overpayments,” Garcia says.

3.  The ruling is not final. Because a DC Circuit Court made the ruling, it can be appealed to the U.S. Supreme Court. However, “CMS is unlikely to prevail and instead, CMS will likely adjust the rule to comply with the decision, most easily by recognizing the differences between Traditional Medicare and Medicare Advantage data in applying the concepts of overpayment to risk adjustment,” Trembowicz says.

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By Karen Appold

On July 16, President Trump nominated Judge Brett Kavanaugh, 53, to the Supreme Court seat being vacated by retiring Justice Anthony Kennedy. Kavanaugh is a conservative jurist who served on the U.S. Court of Appeals for the D.C. Circuit since 2006. A graduate of Yale and then Yale Law, Kavanaugh clerked for President Kennedy and then worked for independent counsel Kenneth Starr, assisting with Starr’s investigations into President Bill Clinton.

Although Kavanaugh’s paper trail on health policy is not vast, it does include some intriguing clues about how he might rule on future cases, says Daniel Ehlke, PhD, associate professor, Health Policy and Management, SUNY-Downstate School of Public Health in Brooklyn, New York. Given Kavanaugh’s previous stances and voting history, here’s a look out how he could impact healthcare legislation.

1. He might support limiting government regulation in healthcare. In Seven-Sky v. Holder, which challenged the enforcement of the minimum essential coverage or individual mandate required under the ACA, Kavanaugh authored the dissent opinion. “Although he did not make a decision on the merits in this case, he indicated that the individual mandate may be under the purview of the federal tax code and that only the IRS could assess, collect, and enforce the tax penalty,” says Maria D. Garcia, JD, of counsel, KozyakTropin& Throckmorton, Coral Gables, Florida. “Regarding future ACA legislation, it is probable that Kavanaugh would be amenable to limiting government regulation of the healthcare market.”
2. He might support FDA’s oversight of experimental drugs. In the 2007 case, Abigail Alliance for Better Access to Developmental Drugs v. von Eschenbach, Daniel E. Dawes, JD, associate professor, Complex Health Systems, Nova Southeastern University, Fort Lauderdale, Florida, says Kavanaugh, along with the 8-2 majority, concluded that, “there is no fundamental right ‘deeply rooted in this nation’s history and tradition’ of access to experimental drugs for the terminally ill.”

“The court sided with the FDA and upheld the process for how the FDA should provide access to experimental drugs,” Garcia says. “Thus, although Kavanaugh has ruled against the FDA in other cases, here Kavanaugh showed support for FDA oversight in specific instances for the use of unapproved drugs. This may play a part in his future decisions.”

3.  He might favor government policies regarding pharmaceuticals. In a number of cases, Kavanaugh has ruled to maintain the status quo of deference to the FDA and seems to agree with its objective of ensuring systems and approaches are in place to protect consumer safety, Dawes says. “If he becomes a member of the Supreme Court, he could very easily continue this path of deference to the government agencies that have managed the pharmaceutical industry.”

In the 2016 Cytori Therapeutics v. FDA case, Kavanaugh said, “a court is ill-equipped to second-guess that kind of agency’s scientific judgment.” “Considering that the Trump Administration has singled out and is keen on reforming the pharmaceutical industry, and Kavanaugh seems sensitive to legislative and administrative actions that bolster healthcare access and quality as well as judicial decisions undermining markets, he may very well rule in favor of the government if their policies do not overreach,” Dawes says.

4.   He might vote conservatively in contraception and abortion cases. In the 2015 Priests for Life v. HHS case, Kavanaugh stated that the ACA’s requirements around mandatory contraception coverage violated the freedom rights of religious employers. “This shows that he is a fairly traditional conservative legal thinker when it comes to contraception and reproductive rights, and will tend to value religious belief, broadly defined, over the health decision-making of women,” Ehlke says. “The blanket protections afforded by Roe v. Wade are therefore very much under threat, even if a national ban on abortion is unlikely.”

Another example of Kavanaugh’s conservative approach to contraception is his willingness to be on record, in a dissent, stating that allowing a 17-year-old immigrant to have the autonomy to decide to get an abortion is a “radical extension of the Supreme Court’s jurisprudence on abortion,” Dawes concludes.

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