JustCare

Tag: Fraud

  • Inspector General finds Medicare telehealth fraud

    Inspector General finds Medicare telehealth fraud

    The Centers for Medicare and Medicaid Services (CMS) began paying for a wide range of telehealth services at the start of the novel coronavirus pandemic in order to help ensure people with Medicare had access to the health care they needed. In year one of the pandemic, more than 28 million older adults and people with disabilities received telehealth services, 88 times the number of services than the prior year. The HHS Office of the Inspector General (OIG) has since discovered some serious telehealth fraud and, in a new report, recommends that CMS take several actions to protect people with Medicare and minimize fraud, waste and abuse.

    Between March 1, 2020 and February 28, 2021, 742,000 health care providers billed traditional Medicare or a Medicare Advantage plan for a telehealth service. Of those, the OIG found a tiny fraction, 1,714 providers whose billing practices pose “a high risk to Medicare.”  They received $127.7 million for their services to 500,000 people.

    Just to say it, the level of fraud detected pales in comparison to the fraud committed by Medicare Advantage plans.

    It’s not clear whether these telehealth care providers delivered necessary services or, for that matter, any services at all. More than four in ten of them are associated with telehealth companies. The OIG recommends much better and targeted CMS oversight of these services. And, CMS said it would follow up on the individual providers the OIG identified.

    But, CMS did not say it would look into telehealth companies, as the OIG recommended. It’s not clear why not. Right now, CMS data cannot identify these telehealth companies systematically.

    The OIG found that seven mental health providers who overbilled Medicare all worked for the same mental health and substance abuse chain in Florida. And, in more than half the cases where the OIG identified suspicious billing, more than one provider was engaged in suspicious billing.

    Here’s more from Just Care:

  • AHA underscores dangers of Medicare Advantage, need for greater accountability

    AHA underscores dangers of Medicare Advantage, need for greater accountability

    Recently, the HHS Office of the Inspector General (OIG) issued a report finding widespread, inappropriate delays and denials of care in Medicare Advantage. Picking up on those findings, the American Hospital Association (AHA) has now sent a letter to the Centers for Medicare and Medicaid Services (CMS) urging it to better oversee Medicare Advantage plans to prevent serious harm to patients and to hold Medicare Advantage plans accountable for their bad acts. Separately, the AHA called on the Justice Department to conduct additional False Claims Act investigations of Medicare Advantage plans for inappropriately denying people care and providers payment.

    The AHA highlights a range of concerns with Medicare Advantage. It calls for CMS collection and public reporting of data on delays and denials of care as well as grievances and appeals at the plan-level. This information is critical. People need to know whether their Medicare Advantage plan is putting enrollees’ health and well-being at risk.

    The AHA also recommends that CMS not pay Medicare Advantage plans in a way that incentivizes them to deny care. It stops short of saying that CMS should stop paying them a capitated fee that bears no relation to the cost of services they cover. But, that’s what needs to happen.

    Right now, Medicare Advantage plans can profit handsomely from denying care. Consequently, they have every reason to avoid including high quality specialists and specialty hospitals in their networks; and, they deter people with costly conditions from enrolling in their plans; they also discourage enrollees with costly conditions from remaining in their plans.

    The AHA does not suggest that CMS cancel its contracts with Medicare Advantage plans that are systematically violating their contractual obligations. That is the best way to protect people with Medicare. CMS should eliminate the bad Medicare Advantage actors so people cannot enroll in them.

    Still, the AHA explains that some Medicare Advantage plans are not complying with standard medical practice when they deny coverage for certain services. These plans are required to apply the same coverage criteria as traditional Medicare. But, they use more restrictive criteria that can endanger the lives of their enrollees. They deny coverage for care that traditional Medicare pays for.

    Moreover, the AHA highlights how the prior authorization protocols of some plans require much time and resources, driving up the cost of care. They create delays for patients in accessing needed care, often to the detriment of their health. These processes should be streamlined and uniform for all plans.

    In its pitch to the Justice Department, the AHA asked the Justice Department to create a task force for Medicare Advantage investigations. The government should impose civil and criminal penalties on Medicare Advantage plans that wrongly deny enrollees care and deny payment to providers for medically needed care. In their view, these penalties would prevent fraud.

    Here’s more from Just Care:

     

  • Avoid bad Medicare Advantage plans

    Avoid bad Medicare Advantage plans

    Medicare Annual Open Enrollment runs until December 7. If you’re enrolling in Medicare for the first time, you have a choice between traditional Medicare, which is government administered and a Medicare Advantage plan, which is administered through corporate health insurers. For easy access to the care you need with predictable costs, traditional Medicare is the clear choice; you will need supplemental insurance either through a former employer, Medicaid or the individual market to protect yourself financially. If you are in good health and don’t want to spend money for supplemental coverage to fill gaps in traditional Medicare, here’s what to consider to avoid enrolling in a bad Medicare Advantage plan.

    Don’t believe what the MA plans tell you; think about what they don’t tell you

    You are often locked in to Medicare Advantage, even if you make the wrong MA choice

    Can you make a good Medicare Advantage choice?

    Can you afford your care in Medicare Advantage?

    Oversight

    Cost to taxpayers

    Fraud

    How MA differs from traditional Medicare

  • Dental fraud: How to protect yourself

    Dental fraud: How to protect yourself

    Daryl Austin writes for Kaiser Health News about dental fraud. Yes, dentists sometimes identify problems with your teeth in order to be able to perform services that are in fact unnecessary. It’s a way to generate revenue off of trusting patients. How can you protect yourself?

    One dentist described how he was fired from his practice back in the 1990s because he told a patient that she did not need a porcelain cap on a tooth that another dentist in his practice had said was needed. Dental care fraud continues to this day.

    Because Medicare does not cover dental services and Medicare Advantage plans generally only cover a small piece of the cost, older adults and people with disabilities tend to have to pay for dental services completely or, almost completely, out of pocket. Prices can vary tremendously, so it’s smart to shop around. And, if a dentist recommends a costly service, get a second opinion before getting the service to make sure it is really necessary.

    Health care fraud is estimated to be quite common. As much as 10 percent of all health care spending could be for fraudulent claims according to a study by the National Health Care Anti-Fraud Association. Why is health care fraud so prevalent with dental care?

    In the dental space, dental practices are being bought by big corporations and private equity firms. They care about maximizing profits. To that end, they might encourage dentists to perform costly procedures that might be unnecessary. Their dentists can follow their directions or fear being fired.

    One unnecessary expensive dental treatment to avoid in most cases is quadrant. It could help you if you have severe gum disease. But, it can also wear away your gum tissue, and your gum tissue will not come back. In other cases, dentists recommend crowns when all a patient needs is a filling. Or, dentists might suggest a mini-implant, which has a high failure rate. A regular implant generally is what is needed.

    Before going along with your dentist’s recommended treatment, ask about your alternatives. And, find out what your costs will be.

    Here’s more from Just Care:

  • How to lower health care costs 1 percent at a time

    How to lower health care costs 1 percent at a time

    The goal of the 1% Steps for Health Care Reform Project is to come up with discrete areas where the data show the US could lower health care costs in small meaningful ways. Reform is hard, in part because our health care system is so large, larger than Germany and the United Kingdom. It’s also hard because of the myriad political hurdles associated with reform and the resource and practical constraints that make certain reforms unworkable.

    1% Steps project participants believe that there are many “1 percent” problems that could be solved. They believe that we could take small steps with drug pricing, Medicare payments and health insurance premiums, among other things. As I see it, the small solutions they propose are no more likely to become law than the major reforms we need. They are complicated, might not even achieve one percent savings, and require heavy lifts. There would be plenty of opposition to them from stakeholders. Here are a few of the proposals:

    Michael Chernew and colleagues at Harvard University suggest a very conservative approach to containing ever-escalating doctor and hospital prices in the commercial health insurance market. Rather than a government-imposed cap on provider prices, which would treat everyone equally, they want to prohibit any providers from charging more than five times the 20th percentile of prices at the local level. Of course, this solution would benefit those providers in areas where the 20th percentile is inappropriately high. In effect, it locks in excessive pricing and rewards the providers who have been charging high prices.

    These researchers also suggest that there should be a limit on health care price increases, although they do not say how much that limit should be. Presumably, it would be pegged to the consumer price index. This makes some sense. But, again, it locks in prices that are already way too high, rewarding the providers who are charging these prices and penalizing those who are charging less.

    These researchers understandably recognize that, for these policies to work, states and the federal government must have the ability to oversee and enforce them, although they say nothing about the resources needed to do so or penalties for non-compliance. Often, providers flout obligations when they believe it is more valuable to do so than pay the penalty.

    Zach Cooper at Yale and his colleague Martin Gaynor at Carnegie Mellon propose doing more to prevent hospital consolidation. Right now, 80 percent of the hospital market is highly concentrated, driving up prices. They think the Department of Justice (DOJ) and Federal Trade Commission (FTC) should do more to enforce antitrust laws. And, they propose giving them more resources and more authority.

    The Cooper-Gaynor proposal makes sense in theory. But, in practice, if it were even possible, it would take a few lifetimes to break up all the big hospitals. And, it is not at all clear that we would end up with lower prices or a better health care system. They also propose that Medicare pay the same rates for the same procedures wherever they are undertaken, something Medicare has begun to do.

    Also concerned about antitrust issues, Daniel Kessler at Stanford wants the FTC and the DOJ to look harder at mergers between doctors and hospitals. It’s hard to believe that Congress would pass a law that could be used effectively to stop these mergers, presumably leaving the ones that have already occurred in place. Kessler also proposes that physicians who work for hospitals not be able to be paid higher rates. But, why stop there? That seems as heavy a lift as across the board rate regulation. Lastly, Kessler proposes that Medicare not pay hospitals and doctors more for the same service performed in a high cost setting than in a lower-cost non-hospital setting. CMS is already moving in that direction.

    Stephen Lee at Benesch and Jonathan Skinner at Dartmouth have a plan to reduce Medicare home health care fraud. They believe that changing a form that physicians use to qualify people for home health coverage to ensure home health care is medically necessary would be helpful. Along with this provision, physicians would learn about Medicare funds spent on home care through reports. They don’t explain why physicians would read the reports or care what’s in them.

    They do not want physicians to be able to waive home health copayments, a proposal that is troubling if only because it would keep some low-income people from getting home care or put them into debt unnecessarily. Finally, they suggest that Medicare do a better job of auditing home health care agencies, although they do not factor in the cost of these audits or suggest the need to give CMS additional resources for this undertaking.

    At the end of the day, the 1 percent steps proposed here are as likely to fail as to succeed and deliver very little for the time and energy it would take to get them enacted into law. We should do the heavy lifting for reforms that matter and enact Medicare for All.

    Here’s more from Just Care:

  • Billing fraud pervasive in Medicare Advantage

    Billing fraud pervasive in Medicare Advantage

    In an effort to maximize government payments and minimize expenditures, attorneys David Engel, Gary Azorsky et al. write in MedPage Today that Medicare Advantage plans are engaging in billing fraud. To increase their rates, they are telling the government that their patients have multiple diagnoses. But, to keep their payments to hospitals as low as possible, they are telling hospitals that these patients have a single diagnosis. Talk about two-faced!

    As the authors explain, the Medicare Advantage plans might tell the Centers for Medicare and Medicaid Services (CMS) that a patient has diabetes in order to get a higher payment from CMS for that patient. But, they might not tell the hospital about the diabetes diagnosis when the patient needs surgery to avoid having to pay the hospital cannot a higher rate for the surgery.

    Medicare Advantage plans pay hospitals a fixed amount for each bundle of services they provide a patient. The fee increases when a patient has multiple diagnoses because patients in poorer health can be costlier to treat.

    The HHS Office of the Inspector General found $2.6 billion in fraudulent Medicare Advantage overcharges in one year alone. The Medicare Advantage plans claimed patients had additional diagnoses for which they could provide no supporting documentation. How common are these fraudulent overcharges? It’s hard to know since they are not easy for the government to detect.

    CMS pays Medicare Advantage plans a fixed fee for each member based on demographics and health status reported by the Medicare Advantage plans. But, what Medicare Advantage plans report about their members to CMS may be very different from what they tell hospitals about their members. CMS cannot see whether the Medicare Advantage plans are telling hospitals something different about patients than they are reporting to CMS. And, hospitals cannot see what Medicare Advantage plans are telling CMS about their patients.

    Put differently, the Medicare Advantage plans have a financial incentive to report as many diagnoses as they can for each member to the government; that’s how they increase their revenues. At the same time, they have a financial incentive to hide patients’ secondary diagnoses from hospitals; that’s how they keep hospital charges down.

    The authors argue that the government can stop this type of Medicare Advantage fraud  through the federal False Claims Act, which requires Medicare Advantage plans to pay triple damages and other financial penalties for committing fraud on the government.

    But, the best way to eliminate the fraud is to take the Medicare Advantage plans out of the mix and replace them with Medicare for All. Medicare Advantage plans don’t reduce fraud, they add to it. Short of that, the government should pay these private health plans on a cost-plus basis–for the services they cover and for processing claims–rather than hand them money upfront that incentivizes them to delay and deny care as much as possible in order to maximize profits.

    Here’s more from Just Care:

  • Trump pardons several Medicare fraudsters

    Trump pardons several Medicare fraudsters

    Fred Schulte of Kaiser Health News reports that Donald Trump, on his way out of office, granted pardons or commutations to several Medicare fraudsters. Many of these convicts were serving long jail sentences for major crimes. Who knows what Trump received in exchange for giving these serious criminals their freedom back.

    One man was allegedly responsible for thousands of questionable spinal surgeries. Another man allegedly ripped off Medicare and Medicaid to the tune of $1 billion taken from senior care facilities. All of those pardoned put the lives of vulnerable older adults at risk and ripped off taxpayers.

    Trump said that Senator Robert Menendez of New Jersey and Congressman Mario Diaz-Balart of Florida supported his decision to pardon Salomon Melgen. Melgen was an eye doctor in Florida convicted of defrauding the government of $100 million. He was charged with giving unnecessary treatments to his patients and compromising their health. Trump’s stated rationale: “Numerous patients and friends testify to his generosity in treating all patients, especially those unable to pay or unable to afford healthcare insurance.”

    Trump also pardoned a former doctor and who was an owner of Pacific Hospital of Long Beach, serving a 15-month prison sentence. He was found to have been paying thousands of dollars in kickbacks to doctors who sent patients to Pacific Hospital of Long Beach for unnecessary surgeries.

    Sholam Weiss received a pardon from Trump. He was sentenced to 835 years in federal prison for what some say is the longest sentence every for racketeering, wire fraud, money laundering and obstruction of justice. Trump said that time served–18 years of prison–was enough.

    Trump pardoned John Davis for his crime of accepting over three-quarters of a million dollars in illegal bribes linked to fraudulent Medicare bills of $4.6 million. In Trump’s view, the former CEO of Comprehensive Pain Specialists, a chain of pain management clinics in Tennessee, committed a single crime that did not lead anyone to suffer financially. He belonged home with his three young children after serving four months in jail.

    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:

  • States charge 26 drugmakers with illegally driving up the price of generic drugs

    States charge 26 drugmakers with illegally driving up the price of generic drugs

    In America, we lock people up when they don’t respond to a bench warrant issued because they failed to pay their medical bills. We deny people health care based on their ability to pay.  But, there’s little chance we will punish the CEOs of 26 pharmaceutical companies if states prevail and the companies are found to have illegally driven up the price of generic drugs.

    Stat News reports that 51 states and territories have charged Pfizer, Novartis, Sandoz, Teva and others with price-fixing, manipulating the market for more than 80 generic drugs. They forced Americans to pay more for their generic drugs. The Connecticut press release explains: “These generic drug manufacturers perpetrated a multibillion-dollar fraud on the American public so systemic that it has touched nearly every single consumer of topical products.”

    It’s no surprise that these pharmaceutical companies chose to put their profits ahead of the public good. That’s what they virtually always do. It will be a surprise, however, if the executives in charge of these companies, some of whom are defendants in the case, face more than a slap on the hand. Eight executives have been sued individually.

    The states’ allegation is of a “vast, systemic conspiracy” among pharmaceutical companies between 2009 and 2016. The pharmaceutical companies deny it. Novartis has already settled one suit regarding price-fixing of generic drugs between 2013 and 2015 for $195 million.

    The US pays two or three times what other wealthy countries pay for drugs because Congress gives drug companies monopoly pricing power, in the form of patents, for brand-name drugs, even when they are variants of drugs long on the market. The generic drug market is supposed to be competitive. But, because of a variety of practices, and alleged price-fixing, generic drug prices are far higher than they should be.

    Insurers are sometimes paid well to keep generic drugs off of their formularies. When a drugmaker or Pharmacy Benefits Manager–a middleman–wants to promote particular brand-name drug alternatives, they offer insurers incentives not to put the generic drugs on their formularies. People then do not have access to lower-cost generics unless they pay cash for them.

    There are so many ways pharmaceutical companies flout the law in order to drive up their profits with impunity, at a huge cost to Americans. Most of their abuses cannot happen in other wealthy countries because prices for drugs are regulated by the government. Why Congress gives pharmaceutical companies in the US license to set prices for brand-name drugs is beyond comprehension.

    The US House of Representatives has passed a bill that would regulate the price of a number of drugs in the US. It’s a start. We need regulation of all drug prices. But, the Republican-led Senate is not considering even the House’s modest attempt to regulate prescription drug prices.

    Here’s more from Just Care:

  • Coronavirus: Watch out for Medicare fraud

    Coronavirus: Watch out for Medicare fraud

    Ricardo Alonso-Zaldivar reports for AP that fraudsters are trying to sell older adults and people with disabilities fake coronavirus tests, along with other products and services. They want your personal information. Watch out for these scam artists!

    The US Department of Health and Human Services Office of the Inspector General is witnessing schemes in which scammers offer older people COVID-19 tests as well as “Senior Care Packages.” Some scammers say they have a vaccine, even though no vaccine exists. Some say that President Trump is requiring testing for all older adults and tell you they need your Medicare number, another falsehood.

    The scammers’ goal is to get your Medicare, Medicaid or Social Security number and other personal information. They then use the numbers fraudulently to bill Medicare and other programs for a range of services you don’t need.  If you end up needing those services at a later date, you might have difficulty getting them. Moreover, this raises health care costs and taxes for everyone.

    You should beware of scammers who reach out via phone, social media, or email, as well as scammers who make personal visits. You should know that Medicare will never call you or visit you out of the blue; it will never ask for your Medicare number; it will never try to sell you anything.

    No matter who it is who reaches out, do not release your personal information, even if you think it’s someone who sounds exactly like your child or grandchild. If it’s a call, hang up. If it’s an email, simply delete it. Do not respond.

    Keep in mind that scammers have sophisticated technology to impersonate others. If it’s someone you think you know trying to sell you something or asking for your personal information, to confirm, call the person back and use the phone numbers you have in your contact information.

    You should report fraud to the HHS inspector general’s hotline 800-HHS-TIPS or the National Center for Disaster Fraud hotline is at 866-720-5721.

    Here’s more from Just Care: