JustCare

Tag: Fraud

  • Justice Department sues Anthem for Medicare Advantage fraud

    Justice Department sues Anthem for Medicare Advantage fraud

    Bob Herman reports for Axios that the Department of Justice is suing Anthem for fraud. The lawsuit, filed by the US Attorney’s Office for the Southern District of New York, claims that Anthem intentionally charged the government more for its members in Medicare Advantage plans than it should have in violation of the False Claims Act. We’ve heard this story before.

    Anthem is not the only health insurance company offering Medicare Advantage plans that the DOJ has sued for fraud. Many Medicare Advantage plans have been charged with wrongly overcharging the government to the tune of tens of billions of dollars. The government has not been able to recoup this money.

    The overpayments happen when health insurers claim that their members are in worse health than they actually are. The health insurers are supposed to make sure that their members have the health conditions they claim they have before billing the government higher rates for them. They also are required to pay the government back for any overcharges, which they practically never do.

    It costs the federal government a lot of time and a lot of money to try to recoup the overpayments. And, the health insurers fight back. Billions in government overpayments mean both higher costs to taxpayers and higher premiums for people with Medicare.

    Like the other health insurance companies offering Medicare Advantage plans, Anthem says that its practices are defensible. It also claims that CMS is engaged in a double standard when it tries to recoup money from Medicare Advantage plans based on payment standards it “does not apply to original Medicare.”

    Most people with Medicare–about 36 million– are enrolled in traditional Medicare. With traditional Medicare, they can see virtually any doctor and use any hospital in the US, without a referral or prior authorization. They are protected from unexpected costs so long as they have supplemental coverage–Medigap, retiree coverage or Medicaid. But, the upfront costs can be higher than traditional Medicare for people who need to buy supplemental coverage to pick up the deductibles and coinsurance costs.

    The ranks of people in Medicare Advantage are growing. These plans tend to have few if any upfront costs. The problem is that when you get sick, there are many barriers to care, including narrow networks, limits on where your care is covered, prior authorization requirements and copays. Out-of-pocket costs for in-network care alone can be as high as $6,700 a year.

    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:

  • Medicare Advantage plan “honor system” can breed fraud

    Medicare Advantage plan “honor system” can breed fraud

    The federal government today pays commercial health insurance companies nearly $200 billion a year to provide Medicare benefits to the 20 million people now enrolled in Medicare Advantage plans.  How these commercial health plans spend that money is largely hidden from public view. An opinion piece in StatNews makes the case that the “honor system” in which Medicare Advantage plans operate is one that can breed fraud.

    Medicare Advantage plans, which are in the business of maximizing profits, have an incentive to spend as little as possible on patient care. The federal government pays them not based on the number of services they cover but rather a fixed or capitated rate per enrollee. What the Medicare Advantage plans don’t spend on patient care they get to keep. Not surprisingly, in 2018, the US Department of Health and Human Services Office of the Inspector General found widespread delays and denials of care in the Medicare Advantage program.

    To maximize profits, Medicare Advantage plans also have an incentive to claim that their patients are in poorer health than they in fact are. That drives up health care spending and hurts taxpayers. Several False Claims suits have been filed against insurers for doing just that. Recently, HealthCare Partners Holdings LLC settled a lawsuit and paid $270 million. It had been charged with overstating the health needs of its Medicare Advantage enrollees.  Another recent False Claims suit was filed against Sutter Health, a hospital system in California. It too was charged with overstating the health needs of its enrollees in order to generate higher government revenues and increase its profits.

    The Centers for Medicare and Medicaid Services (CMS) estimates that as much as 10 percent of the money it pays Medicare Advantage plans–$16 billion in FY 2016–is improper. The Government Accountability Office reports that CMS is not using the appropriate tools to detect these improper payments, suggesting that overpayments to Medicare Advantage plans could be far higher.

    The challenge is that CMS cannot easily detect fraud in these Medicare Advantage plans given the cloud of secrecy in which they operate. Usually, it takes a False Claims Act lawsuit by a whistleblower working at one of these companies to expose the fraud and lead the government to take action.

    Here’s more from Just Care:

  • CVS Caremark accused of $1 billion in Medicare drug fraud

    CVS Caremark accused of $1 billion in Medicare drug fraud

    Pharmacy benefits managers (PBMs)–middlemen who determine the list of approved drugs for health insurers and pay pharmacy claims– argue that they drive down drug prices. But, they also can drive drug prices up in a host of ways. StatNews reports on a whistleblower lawsuit that charges CVS Caremark, a pharmacy benefit manager, of reporting higher than actual generic drug prices to the federal government, defrauding taxpayers, Medicare and older adults and people with disabilities.

    According to the Aetna actuary who filed the lawsuit, CVS Caremark overcharged people with Medicare enrolled in a Part D drug plan and the federal government for generic prescription drugs. Put differently, the price CVS Caremark paid pharmacies for generic drugs allegedly was less than it charged Aetna’s Medicare Part D plans. CVS Caremark pocketed the overpayments.

    CVS Health claims the allegations of fraud are “without merit,” but, the whistleblower in this lawsuit discovered that people with Medicare in other Part D plans were paying less for generics than CVS Caremark was charging Aetna Part D plan members. Why would CVS Caremark not have been able to achieve the same low generic prices for Aetna’s Part D plan members as other Part D plans were able to get for their members? And, CVS Caremark charged Aetna Part D plan members significantly more–25 to 40 percent more.

    CVS is currently in the process of buying Aetna. Had it owned Aetna at the time the lawsuit was filed, in 2014, Aetna’s actuary likely would have had no reason to look into the price discrepancy between what its members paid for generics and what other Part D plan members paid. Aetna would have benefited from the overcharges.

    If Congress stepped in and allowed the federal government to negotiate prescription drug prices for everyone–effectively to set drug prices no higher than the average price of the seven wealthiest countries in the world–not only would it bring down drug prices for everyone by nearly 60 percent, but these types of taxpayer and consumer fraud would not be possible.

    If you want Congress to rein in drug prices, please sign this petition. 

    Here’s more from Just Care:

     

  • New Medicare card in the works

    New Medicare card in the works

    The Centers for Medicare and Medicaid Services, CMS, is preparing to release a new Medicare card to better protect people’s identity from theft. If you have Medicare, you should receive your new card in the mail some time between Spring of 2018 and Spring 2019. You do not have to do anything.

    Today, most people have Medicare cards with their Social Security numbers. The new card will switch out your Social Security number for a new Medicare ID number. The new card is designed to prevent identity theft and fraud.

    Beware of strangers offering to help you with your new Medicare card. They might call pretending to be helping you access your new Medicare card. Keep in mind that Medicare will never contact you to ask for or confirm personal information. So, do not give away this information in person, over the telephone or by email to anyone.

    There is no charge for the new Medicare card. It will take as long as a year for CMS to mail out all new cards, so expect to see yours between April 2018 and April 2019. Your doctor will be able to accept your current card or your new card during this time.

    Guard your card and your Medicare ID number. CMS put out this short video explaining how and why to protect your Medicare information.

    Here’s more from Just Care:

  • UnitedHealth charged with enrollment fraud

    UnitedHealth charged with enrollment fraud

    Fred Schulte of Kaiser Health News reports that UnitedHealth, the largest provider of Medicare Advantage plans–commercial insurers expected to deliver Medicare benefits–has been hiding enrollment fraud and other wrongdoings, according to a whistleblower’s claims in a recently unsealed lawsuit. By so doing, it was able to improperly collect almost $1.5 billion in Medicare bonus payments.

    If UnitedHealth is found to have been engaged in fraud, what penalties will it incur? This is not the first fraud suit against UnitedHealth. UnitedHealth, among other insurers offering Medicare Advantage plans, has been charged with involvement in a range of behaviors to increase their revenues that may run afoul of the law. They face at least six cases brought under the Federal False Claims Act.

    In May, the New York Times reported on a lawsuit filed by a former employee of UnitedHealth charging that the company was improperly making its members out to be sicker than they were in order to receive additional payments from Medicare. The Justice Department is investigating the matter and has said it intends to sue UnitedHealth.

    The new whistleblower lawsuit alleges that UnitedHealth was aware that at least one of its agents was forging signatures on Medicare Advantage enrollment forms to make it appear that the company had more members than it actually did and generate more revenues. It says that another agent was offering kickbacks to get people to sign up for a Medicare Advantage plan.

    UnitedHealth allegedly hid these activities and hundreds of member complaints filed against it in order to keep its high Medicare ratings, which we have previously reported are not to be trusted. (You can read our post here: Medicare star ratings of Medicare Advantage plans a farce.)  It reported only 257 of 771 serious complaints in its files. By hiding these quality indicators, UnitedHealth also collected $1.4 billion in quality bonuses from Medicare.

    The whistleblower suit by James Mlaker and David Jurczyk claims that UnitedHealth kept two databases, one with the full set of complaints and one with an abbreviated list of complaints that it shared with the Centers for Medicare and Medicaid Services. It further claims that UnitedHealth either dismissed serious complaints or otherwise discounted them to mislead Medicare.

    Aside from these and other allegations of fraud and other misconduct, the Medicare Payment Advisory Commission (MedPAC) has found that Medicare Advantage plans are less cost-effective than traditional Medicare. Taxpayers continue to spend more per person in Medicare Advantage plans than in traditional Medicare.

    Here’s more from Just Care:

  • Justice Department sues UnitedHealth Medicare Advantage for fraud

    Justice Department sues UnitedHealth Medicare Advantage for fraud

    At the end of March, the U.S. Justice Department joined a lawsuit brought by a whistleblower alleging that UnitedHealth Group committed fraud in its Medicare Advantage (commercial insurance that covers Medicare benefits) business. The charge is that UnitedHealth misrepresented the health status of its subscribers to Medicare in order to increase its Medicare payments.

    Kaiser Health News reports that the breadth of UnitedHealth Group’s alleged fraud is significant. Damages could be more than $1 billion. That said, an investigation by the Center on Public Integrity suggests that fraud and overbilling by Medicare Advantage plans may be costing taxpayers tens of billions of dollars. The Government Accountability Office (GAO) has also reported on significant billing concerns with Medicare Advantage plans.

    When Congress expanded Medicare to include commercial health plan options, the claim was that these plans could bring down Medicare costs significantly. In fact, these plans have restricted people’s choice of doctors and hospitals and driven up out-of-pocket costs significantly for people with complex conditions. In addition, the Medicare Payment Advisory Commission (MedPAC) has found that taxpayers continue to spend more per person in Medicare Advantage plans than in traditional Medicare.

    Less than a third of people with Medicare are enrolled in Medicare Advantage plans, in part because they restrict people’s access to care and can leave members with costly care needs paying well over $6,000 a year for in-network care plus thousands more if they use out-of-network doctors, which they too often have no choice but to do. But, traditional Medicare requires people have supplemental coverage in order to fill gaps and budget for their care. So, people who believe that they will not need care in the foreseeable future may choose a Medicare Advantage plan to save on the cost of supplemental coverage.

    Here’s more from Just Care:

  • Hospices misleading patients, overbilling Medicare

    Hospices misleading patients, overbilling Medicare

    A new report by the Office of the Inspector General (OIG) reveals that some hospices are misleading patients and defrauding Medicare. Hospices did not inform patients as required that when they elect hospice services they forego Medicare coverage of curative services. Hospices also did not engage doctors in some cases to the extent necessary to determine appropriately whether patients were terminally ill.

    Medicare only covers hospice care for patients who are terminally ill, people whose doctors certify that they have six months or less to live, and who choose palliative care to keep them comfortable over care that treats their terminal condition other than hospice care. Under the hospice benefit, patients may receive a variety of services, including doctor’s care, nursing care, medical social services, medical supplies and drugs.

    Most people with Medicare receive hospice care in their homes. In most instances, Medicare does not cover round-the-clock care, so patients generally need additional caregiving services from family, friends or paid caregivers. There is no set number of hours Medicare pays for.

    The OIG found a high number of cases in which patients should not have been enrolled in hospice. OIG also found many instances in which hospices did not disclose to patients and their families that electing hospice care means giving up coverage for care that treats their condition.

    Inappropriate billing of Medicare totalled more than $250 million for hospice general inpatient care. The OIG found that hospices billed inappropriately for this care 31 percent of the time–both when patients did not need it and when the hospices did not provide this level of care. And, the OIG found in another study that hospices typically provided fewer than five hours of care a week for the $1100 Medicare paid them.

    To date some hospice owners have been convicted of fraud and sent to jail for many years for submitting false hospice claims to Medicare. The OIG report did not specify which specific hospices they had found to be overbilling Medicare or committing other fraud; today, nearly two-thirds of Medicare hospices are for-profit.

    A separate Washington Post investigation found that a large number of hospice patients, particularly in for-profit hospices, were leaving hospice care alive, an indicator that something is amiss. Health may improve for a small fraction of people while receiving hospice care, but something is off when more than three in ten people are leaving hospice care alive, as the Washington Post found to be the case in Mississippi (41 percent) and Alabama (35 percent).

    An increasing number of people with Medicare are opting for hospice. In 2013, there were 3,925 Medicare-certified hospice agencies, 2,411 of which were for-profit hospices. And, Medicare spent $15.1 million on hospice care for 1.3 million older adults and people with disabilities.

    Here’s more from Just Care:

  • Penalties on drug companies for fraud shrinking

    Penalties on drug companies for fraud shrinking

    A new Public Citizen report, 25 Years of Pharmaceutical Industry Criminal and Civil Penalties, 1991-2015, reveals that over the last 25 years government has been reducing the penalties it imposes on drug companies for fraud, from billions in fines to what appears like a spanking.  All told, financial penalties comprise only five percent of drug company profits, seemingly making the penalties worth the crimes.

    Between 1991 and 2015, the penalties on 373 settlements totaled $35.7 billion. One in eight of the settlements, around 45 of them, were for criminal activities.  Almost no senior executive went to jail for any of these violations. And, the government has never kept drug companies from participating in Medicare and Medicaid or required drug companies to reduce drug prices for these programs, as a penalty for the fraud.

    Profits for the top eleven drug companies totaled $711 billion over the ten years between 2002 and 2015.  Public Citizen argues that so long as drug companies continue to profit handsomely from their crimes and misdemeanors, we can be sure they will persist.  And, they are costing taxpayers and people with Medicare billions of dollars.

    Of the drug company violations, the most frequent violation has been overcharging Medicare and Medicaid. Off-label marketing is the violation for which the drug companies have paid the steepest fines. Pfizer, Johnson and Johnson, Novartis and GlaxoSmithKline have been among the biggest violators.

    Public Citizen found that the total number of fraud violations has not decreased significantly in the last three and a half years. But, the federal civil penalties for unlawful promotion of off-label drugs has shrunk by 90 percent.

    Criminal penalties dropped even more significantly in the last two years.  In 2012 and 2013, criminal penalties totaled $2.7 billion.  On 2014 and 2015, they totaled $44 million, only 2 percent of the penalties from the two prior years.

    What explains this drop in penalties?  Public Citizen has no answer but thinks perhaps that the U.S. Department of Justice is focusing on other industries. It recommends that government act to deter drug company frauds through far stiffer penalties.

    Here’s more from Just Care on drug companies and drug policy:

  • Beware of Medicare and Medicaid fraud and, if you see it, report it

    Beware of Medicare and Medicaid fraud and, if you see it, report it

    Medicare fraud is prevalent. It wastes billions of dollars and drives up health care costs. It comes in all varieties but generally involves bills to Medicare for services that were never provided. You can help identify and report it to the Office of the Inspector General or Medicare if your doctor or hospital bills reflect services you never received.

    Earlier this year, the Justice Department and the U.S. Department of Health and Human Services announced charges against 243 people, including more than three dozen doctors and nurses, for participating in $712 million in Medicare and Medicaid fraud through inappropriate billings. In some cases, services were unnecessary and in others they were never performed.

    In this instance, fraud schemes involved a range of services, including home care, psychotherapy, physical therapy, durable medical equipment and pharmacy fraud.

    Since the inception of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) in 2007, the Medicare Fraud Strike Force operations have charged more than 2,300 people with falsely billing Medicare for more than $7 billion.