JustCare

Tag: UnitedHealth

  • 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:

  • Judge finds UnitedHealth illegally denied care to thousands

    Judge finds UnitedHealth illegally denied care to thousands

    CNN reports that UnitedHealth was found to have illegally denied care to thousands of its members. Policymakers in Washington should take note of the risk commercial health insurers may pose to Americans and question their viability. Why do the politicians behave as if they are fenced in?

    Judge Spiro of the US District Court for the Northern District of California has yet to set the punishment. What is clear, however, is that UnitedHealth—the largest mental health insurer—established mental health coverage guidelines that wrongfully and systematically denied its enrollees benefits to which they were entitled. It illegally denied its enrollees access to needed care–in this case, mental health care. The judge also found that UnitedHealth’s medical directors were misleading in their sworn testimony.

    Most important, the judge found that UnitedHealth focused on cost-cutting over appropriate treatment.  Cost-cutting through wrongful delays and denials of care appears to be widespread in commercial health plans. See this report from the Government Accountability Office.

    If United Health’s medical directors are wrongly denying mental health care, isn’t it reasonable to assume that its medical directors are wrongly denying other needed care? There’s good reason to believe that the wrongful denials affect not only the 50,000 enrollees needing mental health care but the hundreds of thousands of enrollees needing other care.

    United Health’s medical directors are supposed to adhere to particular effective treatment guidelines for people with mental health issues. They did not. As a result, these patients received a lower level of care than appropriate, putting them at risk of worse health outcomes.

    Now, UnitedHealth and other commercial insurers are trying to keep CMS from getting more patient encounter data from people enrolled in their Medicare Advantage plans. This data could help show whether enrollees are getting needed care or going without it. So, naturally, the insurers want to keep it from government scrutiny.  Taxpayer dollars pay for this care; the public should be able to see what it is paying for.

    The lack of accountability in the commercial health insurance system is untenable. It’s one of the key reasons that we pay more for our health care and get poorer health outcomes than people in other wealthy countries with government-administered health care,  We need Medicare for All.

    If you want Congress to pass Medicare for All, please sign this petition.

    Here’s more from Just Care:

  • Part D insurers bilk Medicare and taxpayers

    Part D insurers bilk Medicare and taxpayers

    The Wall Street Journal reports on a longstanding practice of health insurance companies, which offer Medicare Part D prescription drug benefits, bilking Medicare and taxpayers. As a result, the government overpaid these insurers to the tune of more than $9 billion over ten years. How did this happen and when will it stop?

    As the WSJ explains, the Centers for Medicare and Medicaid Services (CMS) pays these insurance companies in two parts, based on federal legislation. The goal is to help ensure that they keep down Part D premiums, as well as to protect the insurers if they end up with too many members who take a lot of prescription drugs. But, the result is that many of the insurers, including the very biggest, project their base costs to be significantly higher than they end up being. These insurers benefit from their overestimates.

    Under federal law, if Part D insurers estimate their costs at up to 5 percent more than they spend on prescription drugs and administration, they can keep the full amount of the overestimate. That money is on top of the profits embedded in their estimates, which are part of their administrative costs. If their estimate is more than 5 percent above their costs, they get to split the extra dollars, above the 5 percent, with the government.

    It’s a confusing formula. But, there are some big takeaways. Part D insurers make off like bandits with taxpayer dollars if they overestimate their costs. If Medicare administered the drug benefit directly, it would save billions of dollars. If it negotiated drug prices or paid drug prices based on the average of what other countries pay, it was save some $250 billion a year more.

    CVS Health, UnitedHealth and Humana, three of the largest Part D insurers covering about half of all Part D participants, profit most at the expense of taxpayers. And, CVS effectively concedes that it cannot afford not to overestimate costs if it is to protect its finances.  “[W]e can’t have years where we lose money.”

    The WSJ analysis revealed that almost seven in ten people with Medicare were enrolled in a Part D plan that overestimated its costs by 5 percent or more. More than nine in ten people (93 percent) enrolled in a  UnitedHealth Part D plan were in a plan that had overestimated costs by at least 5 percent.

    The big Part D health insurance companies have the data they need to submit accurate bids to CMS. They would not so consistently overestimate their costs to such a high degree if there were a financial disincentive for them to do so. But, they have every incentive to overestimate their costs, bilk taxpayers and deliver their shareholders greater returns. Rather than penalizing them for their overestimates, the government rewards them. It allows the insurers to keep all of the excess funds up to five percent, along with some of the excess funds over that amount.

    Isn’t it time for the government to rein in drug prices and fold the prescription drug benefit directly into traditional Medicare?

    Here’s more from Just Care:

  • Insurers donate to Democrats in attempt to undermine support for Medicare for all

    Insurers donate to Democrats in attempt to undermine support for Medicare for all

    Tarbell reports that commercial health insurers are supporting Democrats with larger campaign contributions as a way to undermine their support for a government-administered Medicare for all health care system that does away with commercial insurance.

    An increasing number of people are supporting Medicare for all, which would do away with for-profit insurance in the US. The latest Kaiser/Washington Post poll shows that a little more than fifty percent of Americans (51 percent) support government-administered Medicare for all. Only 43 percent of Americans are against it. And, many members of Congress are following the public’s lead.

    To cover their bases and protect their industry, the five largest for-profit health insurers—Aetna, Anthem, Humana, Cigna and UnitedHealth—are using their political action committees to support members of Congress on both sides of the political aisle. They have given more than $1.6 million to House campaigns alone. One member of Congress, Joseph Crowley, whom the insurers believed would be their ally, lost his primary race to Alexandria Ocasio-Cortez, who supports Medicare for all.

    Other House Democrats who are recipients of the health insurers’ financial support are Cheri Bustos of Illinois, Jim Hines of Connecticut, Ron Kind of Wisconsin, Ann McLane Kuster of New Hampshire, John Larson of Connecticut and Richard Neal of Massachusetts.

    The health insurers would likely be very happy with Medicare Advantage for all, doing away with government-administered traditional Medicare. Of course, what they and their allies do not explain and what the public needs to understand is that Medicare Advantage would look very different if it were not competing with traditional Medicare. Costs would skyrocket; today, traditional Medicare holds doctor and hospital costs down for the Medicare Advantage plans. And, Medicare Advantage networks would shrink; today, Medicare Advantage plans need rich networks in order to compete with traditional Medicare. Moreover, Congress would have the ability to cut payments to Medicare Advantage plans and shift more costs to older Americans and people with disabilities with Medicare.

    The health insurers are giving considerable support to the New Democrat Coalition, a pro-business, more centrist body of 68 House members than the Congressional Progressive Caucus, with 76 members.

    If you support Medicare for all, please let Congress know. Sign this petition.

    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:

  • Warning: Your drug copay may be higher than the drug’s cash price

    Warning: Your drug copay may be higher than the drug’s cash price

    It’s bad enough that lack of competition empowers drug companies to set prices sky high for so many important drugs. And, not surprisingly, one in four people in the U.S. say that they struggle to pay for the drugs they need. It turns out that, if you have drug coverage, your drug copay may be higher than the drug’s cash price, and your pharmacist won’t tell you.

    Bloomberg news reports that pharmacy benefit managers PBMs, which contract with pharmacies to pay for drugs on behalf of your health plan, force pharmacists to charge you the insurer’s copay, even when the pharmacy sells the drug for less.  These PBMs or at least Optum Rx and Catamaran, owned by UnitedHealth Group and Humana’s subsidiary PBM, forbid pharmacists from telling you that you’ll save money if you don’t use your insurance to get the drug.

    How does the deal between the PBM and the pharmacy work exactly? The pharmacy turns over the difference between the copay and the actual cost to the PBM. And, according to KARE11, the PBM shares in the profits with the health plan.

    For example, KARE11 found at pharmacy:

    • Doxycycline copay: $46.14 v. cash price $26.95.
    • Venlafaxine copay: $67.13 v. cash price: $24.99

    The extent to which the health plan benefits from these PBM “clawback” contracts is not clear.  But, we’re talking real money. Because of these deals between PBMs and pharmacists, consumers are handing over hundreds of millions of dollars to the PBMs. Not surprisingly, there are more than a dozen lawsuits against insurers contracting with PBMs that are leading people to pay more for their drugs than they should.

    If you are struggling to pay for your drugs, you might consider buying your drugs online or abroad, as millions of Americans are now doing.

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

    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: