Tagged Medicare

Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth

The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.

Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.

Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.

UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. “We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules,” he wrote in an email.

Burns also said that “litigating against Medicare Advantage plans to create new rules through the courts will not fix widely acknowledged government policy shortcomings or help Medicare Advantage members and is wrong.”

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.

“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the “winners here are going to be American taxpayers.”

Burns also contends that the cases against UnitedHealth could potentially exceed $1 billion in damages, which would place them among the top two or three whistleblower-prompted cases on record.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.

On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.

“If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars,” Hanagami said.

David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is “deeply concerned by ongoing improper payments” to Medicare Advantage health plans.

These overpayments “undermine the finances of the overall Medicare program,” he said in an emailed statement. He said his group supports “more rigorous oversight” of payments made to the health plans.

The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.

The federal Centers for Medicare & Medicaid Services said in draft regulations issued in January 2014 that it would begin requiring that Medicare Advantage plans report any improper payment — either too much or too little.

These reviews “cannot be designed only to identify diagnoses that would trigger additional payments,” the proposal stated.

But CMS backed off the regulation’s reporting requirements in the face of opposition from the insurance industry. The agency didn’t say why it did so.

The Justice Department said in an April 2016 amicus brief in the Swoben case that the CMS decision not to move ahead with the reporting regulation “does not relieve defendants of the broad obligation to exercise due diligence in ensuring the accuracy” of claims submitted for payment.

The Justice Department concluded in the brief that the insurers “chose not to connect the dots,” even though they knew of both overpayments and underpayments. Instead, the insurers “acted in a deliberately ignorant or reckless manner in falsely certifying the accuracy, completeness and truthfulness of submitted data,” the 2016 brief states.

The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them.

Categories: Cost and Quality, Courts, Health Industry, Medicare

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Viewpoints: Short Shrift For Mental Health Coverage; Medicare’s Firewall From ‘Harmful’ Changes

A collection of opinions on health care from around the country.

Boston Globe: Changing Attitudes Is Harder Than Changing The Law 
Someone trying to access mental health care is twice as likely to be denied coverage by a private insurer than someone seeking surgical or other medical care, according to a survey of 84 insurance plans in 15 states by the National Alliance on Mental Illness. Matt Selig, executive director of Health Law Advocates, a Boston-based nonprofit group that represents low-income residents, said that last year alone his agency opened cases for 158 people who were denied coverage for mental health or substance use treatment, nearly half of them children. (Kevin Cullen, 3/27)

Arizona Republic: McCain Can Stop Cuts To Seniors’ Health Care
The future of Medicare and Medicaid may depend on John McCain. He is one of a handful of Senate Republicans who could serve as a firewall against harmful changes to this crucial program that Arizona seniors rely upon. … Looking down the road, the majority in Congress has also proposed to privatize Medicare and raise the eligibility age from 65 to 67. These actions could reduce health care coverage and increase out-of-pocket costs for Arizona’s 1,134,000 seniors and people with disabilities. (Max Richtman, 3/27)

Los Angeles Times: Note To Republicans: Drop The Crusade Against Planned Parenthood
Millions of Americans who rely on the Affordable Care Act for their insurance coverage dodged a bullet last week when Republican infighting killed a bill by the House GOP leadership to repeal and replace the healthcare law. So, thankfully, did Planned Parenthood. Embedded in the bill was a provision to bar federal funding temporarily for this well-regarded and crucial healthcare provider, which the GOP has tried, obsessively, to dismantle for years. (3/28)

St. Louis Post-Dispatch: Saluting Our Doctors: The Calm Within The Storm
For many, the role of physicians in hospice is especially important — as they attend to patients and families at this most vulnerable time, guiding and comforting them through the toughest decisions they will ever make. What kind of quality of life does the patient want? What side effects can be expected from chemo or certain medications? What’s the best way to deal with pain? It’s a role hospice doctors readily accept. (Dr. Hashim Raza, 3/28)

The New York Times: Training Your Brain So That You Don’t Need Reading Glasses
By middle age, the lenses in your eyes harden, becoming less flexible. Your eye muscles increasingly struggle to bend them to focus on this print. But a new form of training — brain retraining, really — may delay the inevitable age-related loss of close-range visual focus so that you won’t need reading glasses. Various studies say it works, though no treatment of any kind works for everybody. (Austin Frakt, 3/27)

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Federal Government Takes In $22 Billion In Fines Paid By Health Companies Since 2010

Stat looked at data from 39 agencies to analyze which segments of the health care industry have settled with the government. It found that pharmaceutical companies paid the most, accounting for almost 80 percent of penalties.

Stat: Who Paid The Biggest Fines In Health Care?
When you think of business expenses in the health care industry, you probably don’t think about this mostly hidden cost: settlements made with government agencies. From 2010 to 2017, pharmaceutical companies, health care service providers, and producers of medical equipment and supplies paid the federal government more than $22 billion to settle legal cases. STAT analyzed data from 39 federal regulatory agencies that initiated legal actions against health care companies. In some instances, the companies settled cases without acknowledging any wrongdoing. (Bronshtein, 3/27)

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State Highlights: Ga. House Panel Approves Bill To Reduce ‘Surprise’ Medical Bills; Two Anti-Abortion Measures Clear The Texas Senate

Outlets report on news from Georgia, Texas, Colorado, New Jersey, Connecticut, Massachusetts and Ohio.

Georgia Health News: House Panel OKs New Plan To Halt ‘Surprise’ Bills; Doctors Voice Opposition 
The House Insurance Committee on Monday passed revamped legislation to reduce “surprise billing,’’ in which patients using hospitals in their insurance network may still get unexpected bills from doctors who are not in the network. Consumers who have procedures or visit ERs at hospitals in their networks often get separate bills for hundreds or even thousands of dollars from non-network doctors who were involved. These bills can come from ER doctors, anesthesiologists and radiologists, among others. (Miller, 3/20)

Texas Tribune: Texas Senate Passes Two Anti-Abortion Bills
Two GOP-backed anti-abortion bills passed the Texas Senate on Monday — one that would prevent parents from suing doctors if their baby is born with a birth defect and another that would require doctors to make sure a fetus is deceased before performing a certain type of abortion. Sen. Brandon Creighton’s Senate Bill 25, a “wrongful births” bill designed to prevent doctors from encouraging abortions to avoid lawsuits, passed 21-9. Creighton said without it, doctors have “an invitation to be sued for just practicing medicine” and might not want to work in the state. (Evans, 3/20)

Denver Post: Fingerprint-Based Criminal Background Check Legislation For Colorado Health Care Professionals Passes Key Hurdles
Spurred on by concerns that dangerous criminals are getting hired to care for ill, disabled and frail patients, legislation that would require fingerprint-based criminal background checks for health care professionals in Colorado passed key hurdles this month. House Bill 17-1121, sponsored by Rep. Janet Buckner, D-Aurora, recently cleared two key House committees and appears headed to the Senate for final consideration. (Osher, 3/20)

Houston Chronicle: Health Agency Investigating Its Privatization Of Medicaid Transport Program 
The Texas Health and Human Services Commission has opened an internal investigation into the bungled privatization of a program that transports poor Texans to medical appointments. The probe by the commission’s inspector general, Stuart Bowen, will examine why officials gave lucrative contracts for administration of the program to companies and nonprofit organizations that did not provide cost information and, in some cases, scored poorly on the state’s own rating system. (Rosenthal, 3/20)

Houston Chronicle: One Health Care Disparity Appears To Widen In Houston Area 
It takes less time for a new patient to see a doctor in Houston than the national average, but a health care study also finds the percentage of physicians who accept Medicaid and Medicare remains much lower than in other major cities. Taken together, the two measurements could signal a widening disparity in access to health care based on income and insurance availability in Houston, said Phillip Miller, vice president of communications for Merritt Hawkins, a leading national physician search and health care consulting firm. (Deam, 3/20)

The Philadelphia Inquirer: 31 New Jersey Patients Infected After Injections For Knee Pain
New Jersey health officials have identified 31 patients who became infected after receiving injections to treat knee pain at a clinic in Wall Township, Monmouth County. State and local investigators identified “infection control issues” during an inspection of the clinic on March 13, said Donna Leusner, a spokeswoman for the state Department of Health. At least 20 of the patients at Osteo Relief Institute Jersey Shore have needed surgery to treat their infections, said David A. Henry, health officer for the Monmouth County Regional Health Commission. The investigation is ongoing, he said. (Avril, 3/20)

The CT Mirror: The Health Care That Happens Outside The Doctor’s Office 
[Nadia] Lugo was working as a community health worker, a role many people involved in health care in Connecticut see as a key way to improve care for high-need patients. The job involves bridging the medical and social service systems and the many other factors in people’s lives that can have as much or more impact on their health than medical care – things like housing, transportation and food. (Levin Becker, 3/21)

Boston Globe: Lawmakers Wrestle With Changes To Marijuana Law
State revenue officials predicted taxes on marijuana could eventually bring in more than $100 million each year. The attorney general’s office encouraged lawmakers to clarify how cities and towns can prohibit pot stores. And a long bearded man argued that bills to adjust the state’s new marijuana law are “essentially shredding the will of the people.” (Miller, 3/21)

Columbus Dispatch: Should Only Ohio Residents Be Allowed To Grow Medical Marijuana In State?
People who want to grow medical marijuana in Ohio are certain about one thing: they don’t want outsiders coming in to take over. The vast majority of more than two-dozens speakers at a public hearing today on marijuana cultivation rules said there should be a residency requirement for those granted licenses to grow pot legally under a new state law. (Johnson, 3/20)

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Mayo Clinic Head Backpedals After Saying Hospital Should Prioritize Patients With Private Insurance

“In an internal discussion I used the word ‘prioritized’ and I regret this has caused concerns that Mayo Clinic will not serve patients with government insurance. Nothing could be further from the truth,” Dr. John Noseworthy said.

Stat: Mayo Clinic CEO ‘Regrets’ Statement On Prioritizing Private Insurance Patients
Facing a possible civil rights investigation, Mayo Clinic’s chief executive is backpedaling from statements he made to employees about prioritizing the care of privately insured patients over those on Medicare and Medicaid. Dr. John Noseworthy issued a press release late Friday saying that he regrets that the wording he used caused confusion about the hospital’s commitment to serving patients with government insurance. He sought to correct the record after Minnesota regulators said they are looking into potential legal violations based on his comments. (Ross, 3/17)

The Associated Press: Mayo Clinic Faces Questions After CEO Comments On Insurance
John Noseworthy’s comments were made late last year in a videotaped speech to staff but surfaced only this week after a transcript of his speech was obtained by the Star Tribune newspaper. The Mayo Clinic has verified the transcript is accurate. Noseworthy said in a statement Friday that medical need will always be the top factor in scheduling an appointment. (Forliti, 3/17)

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Voices On The Impact Of The American Health Care Act: Who’s Talking? Who’s Not?

Opinion writers take aim at comments made by some of the Republican plan’s pitch men while also noting the interests that are staying silent as the debate continues. They also highlight the role of key players and personalities such as Health and Human Services Secretary Tom Price.

WBUR: IPhones Vs. Health Care: Demonizing The Poor
The day after [Jason] Chaffetz spoke, the Utah Republican walked this hateful and hate-filled statement back. But we know that such retractions are only the sleazy “part two” of an utterly cynical smear campaign.It’s open season now on all vulnerable groups, and taking target practice on poor people — who have absolutely no way to voice their point of view as widely as the congressman — is an old trick that doesn’t get any more appetizing when the accusations are updated from Cadillacs to iPhones. (Janna Malamud Smith, 3/15)

The Washington Post: No, There’s No ‘War On Men’ In Health Care
Last week, during a committee hearing on the Republicans’ health-care plan, Rep. Mike Doyle (D-Pa.) asked Rep. John Shimkus (R-Ill.) to name a mandated benefit in the Affordable Care Act to which he objected. Shimkus replied: “What about men having to purchase prenatal care?” Shimkus is probably not the only member in Congress who believes that forcing men to purchase health insurance that includes maternal care is unfair; it represents what some have characterized as a war on men, as several conservative health-policy wonks also have argued. (See, for example, Linda Gorman’s “Obamacare’s War on Men.”) (Tsung-Mei Cheng and Uwe Reinhardt, 3/14)

The Washington Post: Can You Guess Which Group Has Been All But Silent In This Latest Health-Care Debate?
Can you hear it? No, you can’t. Ever since the Republicans released their health-care plan, there’s been a lot of noise. Of course, the Democratic opposition has been crying foul. Right-wingers are saying it doesn’t go far enough. Free marketers and the insurance industry worry that it doesn’t give enough freedom to insurance companies. Doctors are complaining that there won’t be enough insurance money available to pay their bills. Medical students think we should have a single-payer system. Some believe the legislation is being pushed through too fast. Others lament the lack of bipartisanship in the bill. The Congressional Budget Office concludes that millions will be left without coverage. Everyone seems to have a big problem with it. (Gene Marks, 3/14)

Los Angeles Times: Trump Sells A Bill Of Goods To Obamacare ‘Victims’
Not long after the Congressional Budget Office reported Monday that the House GOP leadership’s proposal to “repeal and replace” Obamacare would nearly double the number of uninsured Americans, President Trump held a meeting in the White House with about a dozen people he described as “victims” of President Obama’s 2010 healthcare law. (3/14)

Roll Call: TrumpCare Needs a New Doctor
Before Tom Price was Donald Trump’s Health and Human Services secretary, he was a conservative member of Congress. Before that, he was a mustachioed orthopedic surgeon in Atlanta, Georgia. For the sake of all that’s healthy, let’s hope that in his doctor days, Tom Price focused on the surgery and let his partners tell the patient the bad news. (Patricia Murphy, 3/15)

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Outlooks And Assessments: Criticism Of The House GOP Health Plan Heats Up

In the aftermath of Congressional Budget Office estimates regarding the number of Americans who would lose health coverage under the American Health Care Act, editorial pages move deeper into the discussion with some scalding critiques of the plan and some defenses of how it could help reduce the nation’s deficit.

The Washington Post: The Trumpcare Trap
What we learned from the latest “score” by the Congressional Budget Office of Obamacare and the Trump administration’s “repeal and replace” plan is what we should have known all along. To wit: If people have health insurance, they will use more health services — visits to doctors’ offices, tests, procedures and drugs — and health spending will rise. (Robert J. Samuelson, 3/14)

The Wall Street Journal: The Health Bill’s Fiscal Bonus
The furor over the Congressional Budget Office’s report on the House GOP health bill is concentrated on predictions about insurance coverage, which suits Democrats fine. Lost amid the panic is that CBO shows the bill is a far-reaching advance for the market principles and limited government that conservatives usually favor. (3/14)

Los Angeles Times: Every Single False Republican Criticism Of Obamacare Applies Perfectly To Trumpcare
The nonpartisan Congressional Budget Office on Monday released its analysis of the House GOP’s plan to repeal and replace the Affordable Care Act. The result is about as damning as it gets. … I served on President Obama’s healthcare reform team and worked on the Hill to get the legislation passed. It was apparent to me then that many of the Republicans’ criticisms of the ACA were wrong, and yet they now apply to the House GOP bill that Speaker Paul Ryan introduced last week. (Neera Tanden, 3/15)

The New York Times: Obamacare Isn’t In A ‘Death Spiral.’ (Its Replacement Probably Won’t Be Either.)
If you listen to a typical Republican politician, the Affordable Care Act’s insurance markets are in a “death spiral,” “imploding,” “collapsing” or “will fall of their own weight.” That’s part of the rationale behind the new House proposal to reshape the health care system. On Monday night, House Speaker Paul Ryan repeated this line, even in the face of projections that his plan could lead to 24 million fewer Americans with health insurance in 10 years. “Put this against the backdrop that Obamacare is collapsing,” he said in interview with Fox News. “This, compared to the status quo, is far better.” (Reed Abelson and Margot Sanger-Katz, 3/15)

The Washington Post: The GOP Masterminds Behind Obamacare’s ‘Death Spiral’
House Speaker Paul D. Ryan (R-Wis.) says Obamacare is in a “death spiral,” and he should know: He’s the one who cut the power to Obamacare’s engines and pointed its nose downward. President Trump says, “ObamaCare is imploding and will only get worse,” and he should know: He’s the one who placed the explosives under Obamacare’s foundation. (Dana Milbank, 3/14)

Cleveland Plain Dealer: Know The Basics Of Why Obamacare Stumbled Before Adopting Trumpcare
For all of the debate coming out of Washington on health care reform, there seems to be a lack of a fundamental understanding of the functioning of the health care market, and how and why it has stopped working for consumers. A major misunderstanding is the concept of health insurance. Health insurance is a simple idea — we all agree to pay into a pool and to share the resources we collect for appropriate medical needs. In this manner, the healthy subsidize the sick, in the hopes that resources will be available for them should they ever be in need. (Kevin Schulman, 3/14)

The Washington Post: This May Be The Most Brutal Number In The CBO Report
Plenty has been made of the big Congressional Budget Office finding that 24 million people could lose their insurance under Republicans’ Obamacare replacement over the next decade. … But there’s another number that paints a particularly dire picture for the GOP’s alternative — especially in light of President Trump’s populist rhetoric. According to the CBO, 64-year olds making $26,500 per year would see their premiums increase by an estimated 750 percent by 2026. (Aaron Blake, 3/14)

Arizona Republic: Ryancare Fails This Free-Market Test
Conservatives are up in arms over the Obamacare replacement principally designed and promoted by House Speaker Paul Ryan. Let’s call it Ryancare for symmetry. Most of the fire is aimed at the refundable tax credits in the bill. But those are a pragmatic necessity. Instead, the focus of the ire should be on the remaining Obamacare insurance market regulations and the Senate filibuster rule that makes getting rid of them a political impossibility. (Robert Robb, 3/14)

The Charlotte Observer: Obamacare Spawns A New Lie Of The Year
President Barack Obama told a whopper when he was pitching his health care reform bill. “If you like your health care plan, you can keep it,” was so far off the mark that PolitiFact designated it its Lie of the Year for 2013. Now we have a new contender for 2017, also spawned from Obamacare: President Donald Trump’s promise that no Americans would lose coverage in the Republicans’ repeal of the Affordable Care Act. (3/14)

Los Angeles Times: Seven New Ways The GOP’s Obamacare Repeal Bill Would Wreck Your Healthcare
The headline findings in the Congressional Budget Office’s analysis of the Obamacare repeal bill produced by House Republicans are brutal enough: 24 million Americans losing their health coverage, healthcare costs soaring for many millions more, and the evisceration of Medicaid, all while handing the richest Americans a handsome tax cut. But in its fine print, the CBO report identified at least seven other ways the GOP proposal would damage the U.S. healthcare system. Some would have effects reaching far beyond the middle- and low-income buyers of insurance on the individual market who are the Affordable Care Act’s chief beneficiaries. (Michael Hiltzik, 3/14)

Chicago Tribune: Health Care ‘Access’ Is Not The Same As ‘Coverage’
Watching top Republicans explain their proposed Affordable Care Act replacement can make you wonder who hijacked the English language. For example, if you’re like me, you might have been shocked by the news that 24 million fewer Americans will have health insurance by 2026 if the Republican-proposed alternative passes, according to the nonpartisan Congressional Budget Office — including 14 million fewer people in the next year alone. (Clarence Page, 3/14)

Arizona Republic: 3 Trump Health-Care Lies? You Tell Me
Trump made promises during the campaign and now we’re seeing comparisons to his actions. I’ve picked a few from those being reported about the repeal of the Affordable Care Act. Not alternative facts. Not fake news. Just information. The promise versus the reality. (EJ Montini, 3/14)

Los Angeles Times: How The GOP Heathcare Plan Would Worsen The Opioid Crisis
A drug epidemic is ravaging the United States, and it’s getting worse, not better. More than 52,000 Americans died from drug overdoses in 2015, more than died from automobile accidents or firearms. That’s far more than died from overdoses in any year during the crack epidemic of the 1980s. … But you wouldn’t know that from the American Health Care Act of 2017, the House Republican proposal to repeal Obamacare and replace it with a smaller, cheaper health insurance program. (Doyle McManus, 3/15)

St. Louis Post-Dispatch: CBO Confirms The Disaster That Is Republicare
What’s most astonishing about the Congressional Budget Office analysis of the House Republicans’ health care plan is not the estimate that it would increase the ranks of the uninsured by 24 million over the next decade. Nor is it the savage price increases the bill would impose on low-income older Americans seeking to buy insurance. Nor is it the casual cruelty of cutting Medicaid services to 14 million Americans after 2020. What’s most astonishing is the blatant dishonesty of Republican leaders who Tuesday either denied that any of this would occur, or blithely skated past it. (3/14)

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