JustCare

Tag: Cigna

  • UnitedHealth, CVS and Cigna helped fuel opioid crisis

    UnitedHealth, CVS and Cigna helped fuel opioid crisis

    [Editor’s note: I am reposting this piece because it brilliantly exposes how the drug middlemen “PBMs,” who are supposed to be delivering value to Americans, deliver value primarily to themselves and the insurers they work for. They push opioids to vulnerable Americans without prior authorization because they make hundreds of millions of dollars doing so, even when they know that these opioids are killing people.]

    A recent Barron’s exposé detailing pharmacy benefit managers’ (PBMs) backroom dealings in the opioid crisis should be read by everyone. PBMs, which most Americans encounter only indirectly through their health insurance plans, have quietly amassed enormous power over which medications we have access to — and how much they cost. This power extends not only to routine prescriptions but also, as it turns out, to some of the most devastating public health crises of our time.

    The report reveals that the largest PBMs — CVS Caremark, UnitedHealth’s Optum Rx, and Cigna’s Express Scripts — were heavily involved in the distribution of OxyContin, a drug at the center of the opioid epidemic. Between 2016 and 2017, these companies raked in more than $400 million in fees and rebates from Purdue Pharma, OxyContin’s manufacturer. That these rebates were essentially tied to the volume of opioids sold is not just alarming — it’s emblematic of how these middlemen prioritize profit over public health.

    The role of PBMs in drug pricing and availability has been contentious for years. The middlemen argue that their rebate system helps lower costs for employers and insurance plans, but this claim often falls apart under scrutiny. As Barron’s found, PBMs received as much as 19.75% in rebates from OxyContin sales, depending on the dosage and the number of pills prescribed. The higher the dosage, the bigger the rebate and profits. This system, which rewards higher utilization of a dangerous opioid, contradicts the PBMs’ – like CVS Caremark’s – own professed claims of fighting opioid abuse.

    For years, PBMs have presented themselves as crucial gatekeepers, using their clout to negotiate lower drug prices. But the reality, as the article highlights, is far murkier. PBMs, including CVS Caremark and Express Scripts, claim they pass the majority of rebates back to their clients — figures as high as 99%. Yet, these rebates are negotiated in secret, and consumers rarely see the benefits. The rebates often serve to maintain PBMs’ relationships with drugmakers, who want to secure prime placement on formularies — the list of drugs an insurance plan covers.

    The opioid crisis, as Barron’s demonstrates, could be a chilling preview of how PBM-driven rebate schemes might contribute to other drug pricing scandals. If PBMs have been willing to accept massive rebates from Purdue Pharma in exchange for keeping OxyContin widely available during a deadly opioid epidemic, what other drugs have been pushed to the forefront based on financial incentives rather than medical necessity or effectiveness?

    The documents that Barron’s obtained, many of which were previously confidential, show that PBMs had ample opportunity to stem the tide of opioid overprescribing. They could have placed stricter limitations on OxyContin or required prior authorization (which they make significant use of for medically necessary medications) to ensure that the drug was being prescribed appropriately. Instead, they allowed Purdue to maintain a stronghold on the market. According to memos, PBMs even demanded higher rebates as the opioid epidemic worsened.

    As the article suggests, this isn’t merely a historical issue. The opioid crisis may have peaked in the late 2010s, but its effects are still being felt today. And the practices of PBMs — opaque rebate deals, backroom negotiations and a relentless focus on profit — are still very much in place. While Purdue Pharma and its executives have been held accountable through legal settlements, PBMs have largely escaped similar consequences. The lawsuits against PBMs for their role in the opioid crisis are still ongoing, and CVS Caremark’s $5 billion settlement, finalized last year, didn’t even require an admission of wrongdoing.

    This begs a larger question about the pharmaceutical supply chain as a whole. If PBMs have the power to negotiate how drugs like OxyContin are covered, and if their decisions are driven by maximizing profits through rebates, can they really claim to be stewards of affordable health care? (Regular readers of this newsletter should roll their eyes at that question.)

    For too long, PBMs have operated with little transparency. As the Barron’s investigation shows, this secrecy has allowed them to profit handsomely from one of the deadliest public health crises in U.S. history. The opioid crisis could be the most egregious example of PBM malfeasance, but it’s far from the only one. As long as PBMs continue to operate without appropriate oversight, the American public will remain vulnerable to their influence over drug prices — and, by extension, their health.

    Here’s more from Just Care:

  • Cigna medical directors given little incentive to review prior authorization denials thoroughly

    Cigna medical directors given little incentive to review prior authorization denials thoroughly

    A new Pro Publica report exposes how Cigna requires its medical directors to review prior authorization denials at breakneck speed, preventing patients from getting critical care. One medical director at Cigna revealed that, as of about five years ago, she was required to review so many coverage denials in a day as to keep her from ensuring patients received appropriate coverage for their care. This is yet another reason why enrolling in a Medicare Advantage plan entails significant risk if you develop a costly condition.

    Some states allow health insurance company nurses to decide whether someone in the US should get treatment without oversight by a physician. But, some states do not allow insurers to deny claims without a doctor reviewing them. In those states, a medical director must review the nurses’ decisions; but, health insurers can determine how long their medical directors spend on these reviews.

    A few years ago, Cigna began hiring nurses in the Philippines to make coverage determinations. Cigna’s medical directors in the US reviewed their denials. Dr. Debby Day, a Cigna medical director, explains that Cigna was not giving her the requisite time to do so.

    According to Dr. Day, the nurses in the Philippines have increasingly been inappropriately denying Cigna enrollees coverage. She refused to rubber stamp the nurses’ denials or “click and close” them as many of her fellow medical directors did.

    “Deny, deny, deny. That’s how you hit your numbers,” said Dr. Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”

    In response to a Pro Publica query, Cigna claimed that its medical directors were not permitted to click and close nurses’ care denials. But, Cigna shared information about the number of case reviews each medical director was performing—“the productivity dashboard”– with all of them as a way to boost their productivity. The medical directors who performed fewer reviews were considered less productive.

    Companies in many industries typically study the efficiency of their workers. But, in health care, speedy reviews can lead to inappropriate denials of critical care or coverage for services.

    In January and February 2022, Cigna gave medical directors four minutes to review a prior authorization decision for an expensive treatment. Cigna gave them as little as two minutes to review a request for drug coverage. And, it gave medical directors just four and a half minutes to determine whether a patient should be discharged from hospital.

    As has been previously reported, Cigna and other insurers often use an algorithm to reject certain claims collectively.  On average, medical directors spend 1.2 seconds on those claims.

    Dr. Day spent more time reviewing coverage determinations than most of her peers. She felt that Cigna rewarded those who spent less time reviewing these determinations, without considering the quality of their work.

    In response to a question from Pro Publica about incentives to deny claims, Cigna argued that it took less time to approve them, failing to acknowledge that their nurses did the time-consuming work to “justify” denials and that clinicians simply had to click and close.

    Dr. Day explained that during the first several years she worked at Cigna, she was able to take the time she needed to review cases appropriately, but that all changed a few years ago. Once Cigna hired nurses in the Philippines to conduct the initial case review, Dr. Day found  a lot of mistakes in their case reviews that could lead to inappropriate denials. For example, nurses mistook a patient’s parent for the patient, a patient’s hip for her neck, and a patient’s STD for toenail fungus.

    Dr. Day said that Cigna was not focused on her correcting its nurses’ erroneous denials; rather, it was focused on her need to be more efficient. Cigna told her that if she did not review more cases and boost her productivity score, she could be fired. It’s no surprise she left the company.

    Here’s more from Just Care:

  • Cigna plans to sell its Medicare Advantage business

    Cigna plans to sell its Medicare Advantage business

    The Wall Street Journal reports that Cigna is planning to sell its Medicare Advantage book of business. For nearly $4 billion, why not? While Cigna is a big health insurer, it has the smallest Medicare Advantage footprint of the big insurers. The sale signals the inevitable future of Medicare Advantage–one or two mega insurers with the vast majority of the Medicare Advantage business and all the power to undermine access to care in order to maximize profits.

    Currently, Cigna operates in 29 states. A sale to Blue Cross Blue Shield would boost its power in the Medicare Advantage marketplace. Originally, Cigna had considered buying Humana’s Medicare Advantage book of business, but investors did not receive that plan favorably.

    Cigna is a relatively small Medicare Advantage player with only 599,000 Medicare Advantage enrollees as of September 2023.  UnitedHealth has more than twelve times as many enrollees, 7.6 million. Humana has nearly 10 times as many enrollees, 5.9 million.

    Cigna’s departure from the Medicare Advantage marketplace will be unsettling for its enrollees, but should not come as a surprise. Nothing about a Medicare Advantage plan is reliable. Medicare Advantage management, along with coverage and payment practices, can change all the time. Plans can grow larger through acquisitions or shrink in size.

    Medicare Advantage provider networks also are ever-changing and unreliable. Denial rates and prior authorization rules are not even knowable and according to the Office of the Inspector General, there are widespread and persistent inappropriate delays and denials of care and coverage in some Medicare Advantage plans.

    Hospitals and specialists are increasingly canceling their Medicare Advantage contracts, meaning unreliable access to care for tens of thousands of Medicare Advantage enrollees. But, these providers are canceling in part because of patient safety concerns, meaning risks to health and well-being in Medicare Advantage. The AMA’s doctors report serious concerns with MA prior authorization, to the detriment of patients.

    The Medicare Advantage Open Enrollment period began January 1 and continues through March 31. If you want to be sure you get the care you need when you need it, take advantage of it and switch to Traditional Medicare.

    Here’s more from Just Care:

  • Pharmacies sue pharmacy benefits manager for overcharging them

    Pharmacies sue pharmacy benefits manager for overcharging them

    In a health care world in which, among other things, the government is now overpaying insurers offering Medicare Advantage plans $140 billion this year without seeming to blink, pharmaceutical companies are charging tens of thousands of dollars for some life-saving medicines with no government talk of across-the-board drug price negotiation, and hospital systems are dying because Medicare Advantage plans are not paying their bills, it’s refreshing to learn that pharmacies are fighting back against overcharges. Reuters reports that pharmacies are suing Express Scripts, a pharmacy benefits manager (PBM), in a class action for raising fees on them and reimbursing them at low rates.

    Express Scripts is a company that rakes in billions in profits a year for Cigna from pharmaceutical company rebates it receives for putting high cost drugs on insurance company formularies–the prescription drugs your insurance covers–and steering patients to use them. No kidding. For example, you can read here about how pharmacy benefit managers (PBMs) are getting paid big bucks from Humira’s manufacturer to steer people away from its lower-cost competitors.

    Because the pharmacy benefit managers, often in collaboration with your insurance company, are looking to maximize their profits, you could end up spending more if you get your drugs through your insurance company rather than through Costco mail-order, MarK Cuban’s Cost Plus Pharmacy or a coupon at your local pharmacy. This is true if you have a Medicare Part D prescription drug plan as well. Always check with Costco or another low-cost mail order pharmacy to save money; if that’s not an option, ask your pharmacist whether there’s a less costly option than using your insurance to cover your drugs; there often is.

    Because the pharmacies have the will and the money to take on Express Scripts, they should be able to correct the problem and end the gouging. If only the government would step in on behalf of individuals to keep the pharmacy benefit managers from gouging us.

    The complaint by four pharmaceutical companies accuses Express Scripts of collaborating with Prime Therapeutics to hike up reimbursement rates and fees.

    Here’s more from Just Care:

  • Cigna sued in California for denying coverage 300,000 times in two months

    Cigna sued in California for denying coverage 300,000 times in two months

    Corporate health insurers’ use of AI to deny coverage is too often killing and disabling people. People in Medicare Advantage, people in State health insurance exchanges and people with job-based coverage are all at risk.  Now, Axios reports that a class of people are suing Cigna for using computer software to “deny payments in batches of hundreds or thousands at a time.” Why not? It maximizes Cigna’s profits, and Cigna has so far been able to get away with it.

    Mounting evidence shows that corporate insurers offering Medicare Advantage plans too often deny costly and critical care, including nursing home stays, rehab, home care and hospital care. This is care they are paid to cover and that traditional Medicare covers.

    The Clarkson law firm filed the lawsuit in California claiming that Cigna is violating state law. Cigna is supposed to thoroughly and fairly review insurance claims under California law. Computer algorithms is clearly at odds with that requirement. It’s hard to believe that a judge could find that a speedy computer review of a claim could be fair and thorough. But, these days, anything’s possible.

    The lawsuit claims that Cigna’s AI system denied 300,000 requests for authorization over two months in 2022. The system spent an average of 1.2 seconds on each claim. Thorough? Fair? One Cigna medical director, Cheryl Dopke, denied 60,000 claims in one month. Thorough? Fair? Hardly. California law requires individual review. And four out of five claims that were reviewed were overturned on appeal.

    Use of AI is the latest way health insurance corporations can inexpensively and swiftly turn a huge profit. Who’s designing the computer software algorithms? What’s their goal? As many denials as possible is what’s in Cigna’s economic interest. You have to wonder what questions Cigna asks about the algorithms before buying the software.

    Even some Republicans in Congress appear concerned, including House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.). She wrote Cigna for an explanation. Members of Congress appear to appreciate that people in Medicare Advantage and Medicaid are at risk of wrongful denials. But, what is she and her fellow members of Congress willing to do about it?

    Here’s more from Just Care:

  • Cigna denies medical claims with a “click and submit”

    Cigna denies medical claims with a “click and submit”

    A new Pro Publica report finds that Cigna’s physicians reject millions of their enrollees’ treating physicians’ insurance claims “on medical grounds” each year, without even looking at them. Other major insurers appear to do exactly the same thing. It seems that Cigna and other corporate health insurers see no need to spend money determining whether claims should be paid when they can refuse to pay and save billions of dollars.

    Whatever you think about government-administered insurance, like Traditional Medicare, the government defers to the treating physician to determine whether care is reasonable and necessary and should be covered. But, unlike the government, corporate health insurers come between patients and the care their treating physicians recommend for them. Denying care means maximizing profits; the less they spend on care, the more of the premium dollars they are able to keep for their shareholders.

    The Pro Publica report confirms that the insurers take little time, less than two seconds, when deciding whether to pay certain claims even though, in many instances, these claims are for medically reasonable and necessary services that should be paid.  “We literally click and submit,” one former company doctor said. This behavior would appear to be forbidden under state and federal laws.

    Under both state and federal laws, the insurance company doctors are required to “review” all claims to determine whether they should be denied or not. “Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims,” according to regulators. The goal is to minimize inappropriate denials. Still it appears that Cigna and other insurers believe that physician reviewers can determine whether a claim is covered without looking at patients’ files.

    “Why not deny claims?” seems to be the mantra of some corporate health insurers, if not most of them. They face no penalty for high rates of inappropriate denials. Instead, these insurers burden patients and physicians with having to appeal if they want to be paid. And, the insurers know that in 95 percent of cases, the physicians and patients won’t appeal.

    Only five percent of the time do patients and physicians appeal the insurance company denials. It’s easier for the physician to stop performing the procedures that the insurers deny, even when the patients need them. And, the patients often do not know that it’s generally relatively easy to appeal, they can do it themselves and they have a high likelihood of winning on appeal, if only after many months. Even when they do know they could win on appeal, people might not have the time, energy or ability to file an appeal.

    The Pro Publica story focuses on patients with employer coverage. But, you can bet your bottom dollar that the health insurers use the same tools to reject claims of people in Medicare Advantage plans–the corporate health plans that contract with the government to offer Medicare benefits–as they do for people with employer coverage. So, if you’re in a Medicare Advantage plan and you need costly services, don’t be surprised when your health plan denies coverage for the medically necessary care your treating physician believes you need.

    Here’s more from Just Care:

  • Medicare Advantage gold mine puts traditional Medicare at grave risk

    Medicare Advantage gold mine puts traditional Medicare at grave risk

    Beware of corporate health insurers with eyes on Medicare. To date, these insurers have been taking our money in exchange for offering people benefits through Medicare Advantage plans and then running back to their shareholders with a fat share of their revenue. Healthcare Dive reports that these corporate health insurers have eyes on every Medicare dollar they can get their hands on; they are lobbying heavily for taking over traditional Medicare’s book of business.

    Medicare Advantage plans continue to reap huge profits, so they are expanding into more areas and offering lots of goodies to lure people to enroll. But, what matters most is the quality of the care they are delivering, the costs they are imposing on people with serious health conditions, and the legitimacy of what they are charging for their services. On those issues, we know precious little. What we do know is that government audits over and over again indicate big problems. 

    For sure, these corporate health plans are not competing to deliver high value care to older adults and people with disabilities. They are doing their best to enroll people who are healthy, who don’t use a lot of services, and then claim that some of these people are in need of care coordination in order to reap greater revenue from the Centers for Medicare and Medicaid Services.

    Medicare Advantage plans must have one of the best business models going. They say they are offering people Medicare health care benefits but no one has a clue what that means. We don’t know the extent to which they are pocketing money that should be going towards the health and well-being of people with Medicare or how to hold them to account when they are violating their contracts. What we do know is that many of these plans have high denial rates, some have high mortality rates and others have been found to deliver poor quality care. They are contracting with poorer quality nursing homes and home care agencies to provide services to their members.

    Why Congress would consider giving these corporate health insurers more business is hard to understand if our representatives are putting the interests of their constituents and the national treasury first. Yes, some Medicare Advantage plans are helping people who cannot afford supplemental coverage in traditional Medicare. But, the answer should be to strengthen and improve traditional Medicare, which is far more cost effective and allows people unfettered access to the care they want and need, not to hand more business to corporate health insurers who by at least one recent account are responsible for not meeting their members’ care needs, leading them to die.

    Medicare Advantage plans have a huge bag of tricks to seduce more people to enroll with them in 2021. But, even the Trump administration’s Department of Justice recognizes that at least some of these health insurers are engaging in massive fraud. HealthCare Dive reports a recent DOJ suit against Cigna alleging $1.4 billion in overcharges. There was a suit against Anthem in March and Sutter Health settled a similar fraud suit for $30 million.

    Some might think that these insurers only commit fraud against the government. Keep in mind that these insurers also can profit handsomely by delaying and denying care and creating other administrative and financial barriers to keep people from receiving needed services that Medicare covers. Whether the Medicare Advantage plan you are enrolled in or might be considering switching to does or does not do so is a gamble you should not take lightly.

    Here’s more from Just Care:

  • Health insurers spread lies to promote shareholder value

    Health insurers spread lies to promote shareholder value

    In a Washington Post op-ed, Wendell Potter, president of the Center for Health and Democracy and a former Cigna executive, explains that his job at Cigna was to spread lies to Americans about health care in order to promote value for Cigna’s shareholders. As a result, millions of Americans are uninsured or underinsured today. And, thousands of Americans have died preventable deaths from lack of care during this pandemic.

    In response to Michael Moore’s film, Sicko, in 2007, Potter worked in collaboration with executives at other health insurers to keep Americans from advocating against our for-profit health care system. Sicko claimed that the US corporate health care system was a failure, and Canada’s public health care system worked quite well. They hired a PR firm to develop talking points about the problems with Canada’s health care system. They pulled quotes from unreliable sources and spread falsehoods, misleading Americans to believe that the US health care system was best in class and other public health car systems were seriously flawed.

    As Potter explains, the US’ inability to contain the novel coronavirus and Canada’s relative success demonstrates the superiority of Canada’s system. The US is seeing three times more coronavirus infections per capita and has twice the mortality rate of Canada. The health insurers’ trade association, AHIP, continues to spread nonsense about wait times to get care in Canada when Canadians have far more doctors and better access to medical care than Americans.

    People in Canada have access to COVID-19 testing and treatment without having to worry about the cost. They have no out-of-pocket cost–no deductibles, no coinsurance, no copays. And, when they lose their jobs, they still have health insurance. This helps explain why so many fewer Canadians are dying than Americans.

    If you look at a variety of metrics, people get better health care in Canada. People in Canada are hospitalized less frequently as a result of a chronic condition. They have longer life expectancies, 82 v. 78.6. And, they spend half the amount we do per person on health care. Moreover, their hospitals rely on a global budget and are protected financially when fewer people seek treatment.

    We need a public health insurance system in the US if we care about ensuring Americans receive the care they need. Our private health insurance system is designed not to pay for care, to profit from imposing financial and administrative barriers to care.

    Here’s more from Just Care:

  • Coronavirus and hospital bills: Medicare v. private health insurance

    Coronavirus and hospital bills: Medicare v. private health insurance

    Joseph Goldstein reports for the New York Times on a patient with COVID-19 who was hospitalized for 19 days and received bills totaling more than $400,000. Congress provided hospitals with stimulus funds to help ensure that patients were not billed out of pocket for COVID-19 care. But, unless you have traditional Medicare, which requires hospitals and doctors to bill the government directly, you are at risk of receiving bills for services that you should not be paying.

    Again, Congress passed legislation to keep hospitals from billing patients with private insurance for COVID-19 care. But, there appears nothing to stop hospitals from doing so other than good will. Mount Sinai hospital in New York billed one COVID-19 patient, who had insurance through CIGNA, $401,885.57.

    Thinking the patient was uninsured because it did not have insurance information for her, it discounted her bill by $326,851.63, a “financial assistance benefit.” She was left with $75,000 in costs, even though the hospital had received $63.7 million from the government in COVID-19 stimulus money. Of note, hospitals can charge the federal government directly for uninsured patients.

    Mount Sinai hospital admits that it erred when it billed the patient. It should have gotten her insurance information and billed CIGNA directly. Now, the patient has been left to try to work the bill out.

    The bottom line is that the federal government does not have the ability to keep hospitals and doctors from billing people with private health insurance for services, even when they are not allowed to, as with most COVID-19 care.  [N.B. If the patient had traditional Medicare or, for that matter, if Medicare for All were enacted, the patient would never receive a hospital bill. The patient would not need to spend precious time getting the insurance company to pay and fending off collection notices.]

    Although hospitals should not be billing insured patients directly for COVID-19 care, doctors can bill patients for their COVID-19 services. So, people can be charged significant out-of-pocket costs for their care. In the case involving Mount Sinai hospital, the patient believes she will be liable for as much as $10,000.

    For the uninsured, the federal government has set up a billing system for hospitals to cover the cost of COVID care. It has effectively expanded Medicare to the uninsured, paying Medicare rates for their care.

    Here’s more from Just Care:

  • Corporate health insurers profit by condoning fraud

    Corporate health insurers profit by condoning fraud

    Here’s another reason to support Medicare for All, a single public health insurance system, as well as to beware of Medicare Advantage plans, corporate health plans that contract with the federal government to offer Medicare benefits. A Pro Publica investigation by Marshall Allen reveals that corporate health insurers profit by condoning health care fraud, undermining the health and financial well-being of their members.

    It’s projected that we could bring health care costs down by as much as 10 percent if we could eliminate health care  fraud. It would mean a savings of as much as $120 billion a year in private health insurance spending, not chump change.

    Pro Publica found that one personal trainer in Texas, who was not a medical doctor, billed four big health insurers for his completely fabricated “services” and received $4 million. He billed the insurers as an out-of-network provider.

    The US Department of Justice files thousands of criminal and civil fraud cases each year. But, private health insurers rarely file fraud cases even though they have the data to identify scammers.

    Aetna, Cigna and UnitedHealthcare would not permit Allen to speak with the people on their staff who investigate fraud, most likely because they do so little to combat it on behalf of their members. During 2017 and 2018, in California, which has 14.4 million people with commercial health insurance, private insurers referred just 22 criminal cases to prosecutors. And, the insurers brought just one civil lawsuit over fraud. In stark contrast, in that same time period, California Medicaid, which covers 13 million Californians, filed criminal charges against 321 medical providers and recovered $93 million.

    UnitedHealth provided Pro Publica with a list of just four lawsuits it had brought, where it had won tens of millions of dollars. That’s a pittance given that it had $226 billion in revenue in 2018 alone. What’s more, UnitedHealth and other corporate health insurers do not appear to be willing to provide assistance–not even basic information–as to the frequency with which their patients are treated at a site–to government fraud investigators.  A fraud prosecutor in Los Angeles told Allen that “It suggests we are not on the same page in terms of enforcement and protecting the integrity of the system.”

    Minnesota law requires corporate insurers to refer all cases where there is a “reasonable belief” of fraud. Yet, in 2017, a fraud prosecutor received just two referrals and, in 2018, he received five.The state’s Medicaid unit investigated nearly 600 incidents of fraud and issued 134 indictments. Interestingly, auto insurers made well over 1,000 referrals to the state’s fraud bureau.

    The state fraud reporting law seems to work no differently in the 35 other states that have it. In Georgia, only three of the ten biggest health insurers reported any fraud. Arizona received just 32 referrals in one year.

    The fraud reporting law applies to fully insured health plans, ones where the insurers bear the risk and pay all the bills. It does not apply to self-funded plans, where employers pay the bills with the help of an insurance company administrator. The Department of Labor regulates these plans. Unfortunately, fraud is not one of its priorities.

    Some believe that insurers don’t want to take the time and expend the resources necessary for a fraud investigation. Moreover, going after health care fraud could undermine their network adequacy. If the only specialist in the network is providing poor unnecessary care, the insurer cannot risk losing the specialist. Corporate health insurers might also worry that fraud investigations could have reputational risks for them. What if the prosecutor found the insurer was at fault? Former insurer fraud investigators confirm that insurers don’t want to root out fraud because it hurts their profits.

    The takeaway: Don’t count on commercial health insurers to ensure the integrity of our health care system.

    Here’s more from Just Care: