Whistleblower Alleges Fraud At A Large Medicare Advantage Plan In Seattle and on and on about the last Democrat Debate and more on Medicare for All

72488737_2301802426616070_6529440653267435520_nWhat a unique world we live in. Bernie Sanders, a man running for the position of President, ignores his symptoms of heart disease, has a heart attack, needs stents for his coronary arteries which are obstructed and a few weeks later is back on the difficult road to running for President. What a jerk who I am sure is ignoring his doctor’s advice, who I’m sure has discussed his post-procedure heart disease restrictions including taking stress, etc. easy for at least 6 weeks, or that what is what I would tell my patient. And this is the man who is telling us all how we should all be deciding our health care system. Unbelievable!! Now, with all the whistleblowers coming out of the woodworks, Fred Schulte points out another whistleblower. Group Health Cooperative in Seattle, one of the United States’ oldest and most respected nonprofit health insurance plans, is accused of bilking Medicare out of millions of dollars in a federal whistleblower case.

Teresa Ross, a former medical billing manager at the insurer, alleges that it sought to reverse financial losses in 2010 by claiming that some patients were sicker than they were or by billing for medical conditions that patients didn’t actually have. As a result, the insurer retroactively collected an estimated $8 million from Medicare for 2010 services, according to the suit.

Ross filed suit in federal court in Buffalo, N.Y., in 2012, but the suit remained under a court seal until July and is in its initial stages. The suit also names as defendants two medical coding consultants — consulting firm DxID of East Rochester, N.Y., and Independent Health Association, an affiliated health plan in Buffalo, N.Y. All denied wrongdoing in separate court motions filed late Wednesday to dismiss the suit.

The Justice Department has thus far declined to take over the case but said in a June 21 court filing that “an active investigation is ongoing.”

The whistleblower suit is one of at least 18 such cases documented by Kaiser Health News that accuses Medicare Advantage managed care plans of ripping off the government by exaggerating how sick their patients were. The whistleblower cases have emerged as a primary tool for clawing back overpayments. While many of the cases are pending in courts, five have recovered a total of nearly $360 million.

“The fraudulent practices described in this complaint are a product of the belief, common among [Medicare Advantage] organizations, that the law can be violated without meaningful consequence,” Ross alleges.

Medicare Advantage plans are a privately run alternative to traditional Medicare that often offers extra benefits such as dental and vision coverage but limits the choice of medical providers. They have exploded in popularity in recent years, enrolling more than 22 million people, just over 1 in 3 of those eligible for Medicare.

Word of another whistleblower alleging Medicare Advantage billing fraud comes as the White House is pushing to expand enrollment in the plans. On Oct. 3, President Trump issued an executive order that permits the plans to offer a range of new benefits to attract patients. One, for instance, is partly covering the cost of Apple watches as an inducement.

Group Health opened for business more than seven decades ago and was among the first managed care plans to contract with Medicare. Formed by a coalition of unions, farmers and local activists, the HMO grew from just a few hundred families to more than 600,000 patients before its members agreed to join California-based Kaiser Permanente. That happened in early 2017, and the plan is now called the Kaiser Foundation Health Plan of Washington. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In an emailed statement, a Kaiser Permanente spokesperson said: “We believe that Group Health complied with the law by submitting its data in good faith, relying on the recommendations of the vendor as well as communications with the federal government, which has not intervened in the case at this time.” Ross nods to the plan’s history, saying it has “traditionally catered to the public interest, often highlighting its efforts to support low-income patients and provide affordable, quality care.”

The insurer’s Medicare Advantage plans “have also traditionally been well regarded, receiving accolades from industry groups and Medicare itself,” according to the suit.

But Ross, who worked at Group Health for more than 14 years in jobs involving billing and coding, says that from 2008 through 2010, the company “went from an operating income of almost $57 million to an operating loss of $60 million.” Ross says the losses were “due largely to poor business decisions by company management.”

The lawsuit alleges that the insurer manipulated a Medicare billing formula known as a risk score. The formula is supposed to pay health plans higher rates for sicker patients, but Medicare estimates that overpayments triggered by inflated risk scores have cost taxpayers $30 billion over the past three years alone.

According to Ross, a Group Health executive in 2011 attended a meeting of the Alliance of Community Health Plans, where he heard from a colleague at Independent Health about an “exciting opportunity” to increase risk scores and revenue. The colleague said Independent Health “had made a lot of money” using its consulting company, which specializes in combing patient charts to find overlooked diseases that health plans can bill for retroactively.

In November 2011, Group Health hired the firm DxID to review medical charts for 2010. The review resulted in $12 million in new claims, according to the suit. Under the deal, DxID took a percentage of the claims revenue it generated, which came to about $1.5 million that year, the suit says.

Ross says she and a doctor who later reviewed the charts found “systematic” problems with the firm’s coding practices. In one case, the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.” Overall, about three-quarters of its claims for higher charges in 2010 were not justified, according to the suit. Ross estimated that the consultants submitted some $35 million in new claims to Medicare on behalf of Group Health for 2010 and 2011.

In its motion to dismiss Ross’ case, Group Health called the matter a “difference of opinion between her allegedly ‘conservative’ method for evaluating the underlying documentation for certain medical conditions and her perception of an ‘aggressive’ approach taken by Defendants.”

Independent Health and the DxID consultants took a similar position in their court motion, arguing that Ross “seeks to manufacture a fraud case out of an honest disagreement about the meaning and applicability of unclear, complex, and often conflicting industry-wide coding criteria.”

In a statement, Independent Health spokesman Frank Sava added: “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately.”

Whistleblowers sue on behalf of the federal government and can share in any money recovered. Typically, the cases remain under a court seal for years while the Justice Department investigates.

How would Warren pay for ‘Medicare for All’? Enough evasion, it’s past time for answers.

Chris Truax points out that the last 2 months al anyone who watches the politicians suggesting that Medicare for all is the solution to the healthcare crisis has bombarded the news. Medicare for All will create winners and losers. It’s all very well to say you can’t make an omelet without breaking some eggs unless you’re the egg.

When it comes to doing things, Elizabeth Warren has a plan for everything — and she’s happy to tell you all about it. But when it comes to paying for things, I’m sorry to say, the Massachusetts senator dodges and deflects like a Donald Trump defender.

It’s estimated that “Medicare for All” will cost the federal government an extra $3 trillion a year. That’s more than $9,000 annually from every man, woman, and child in America. Despite being asked, again and again, Warren refuses to acknowledge that paying for this is going to require an across-the-board tax increase — and a pretty massive one, at that. Instead, she keeps talking about how “costs” will go down before she changes the subject to how stressful it is to have your insurance canceled when you get sick or when you have to cope with your mom having diabetes. That’s very true, I’m sure. But we’re talking fiscal policy here.

Warren To Release Plan To Pay For ‘Medicare For All’

Yuval Rosenberg of The Fiscal Times noted that now, just last week Massachusetts Sen. Elizabeth Warren said Sunday she will roll out a plan to pay for an expansive single-payer health care system in the coming weeks, promising the plan would decrease overall costs for the middle class.

“I plan over the next few weeks to put out a plan that talks, specifically, about the cost of ‘Medicare for All’ and how we pay for it,” Warren said at the end of a town hall here at Simpson College. “I will not sign a bill into law that does not reduce the cost of health care for middle-class families.”

Warren’s aides have long suggested she was studying ways to pay for the health care plan originally backed by Vermont Sen. Bernie Sanders, one of her leading rivals for the 2020 Democratic presidential nomination. In recent days, Warren has faced criticism from lower-profile candidates in the race — especially South Bend, Indiana, Mayor Pete Buttigieg and Minnesota Sen. Amy Klobuchar — for her failure to explain how she would pay for the ambitious plan, which would replace private health insurance with generous, universal coverage paid for by the federal government.

“Everybody who is running for president right now knows that families are getting crushed by the high cost of health care,” Warren told the crowd of nearly 500 people. “They also know that the cheapest possible way to make sure that everyone gets the health care that they need is Medicare for All.”

Warren’s statement came after her standard 40-minute stump speech and three questions from attendees, none of whom asked about Medicare for All. The addition appeared to be an attempt to short-circuit recent criticisms of her health care plan.

Warren has previously promised, most recently at the Oct. 15 debate, that no middle-class family would see an increase in overall health care costs. And her aides have said since at least September that she was evaluating ways to pay for Medicare for All. She does not plan to significantly alter the details of the legislation she’s co-sponsored with Sanders in the way Sen. Kamala Harris (D-Calif.) did with her own health care proposal over the summer. Warren said she had been working on the problem of how to pay for the legislation for “months and months.”

“It’s just a little more work until it’s finished,” she said.

For a campaign that has long prided itself on detailed policy proposals, releasing a plan to pay for Medicare for All — which is sure to generate intense scrutiny from the media and her rivals for the nomination — is a high-risk but likely necessary move. Whether or not a plan for Medicare for All would lower costs for the middle class would rely heavily on complicated details, including how progressive the tax system supporting the plan is and how aggressively the government is able to control the cost of health care.

Estimates of how much the plan would cost vary wildly, as do estimates of how much switching to a single-payer system would increase or decrease overall health care costs.

Buttigieg, in particular, has aggressively questioned how Warren would pay for the plan, and said she is being dishonest by not saying whether or not taxes would go up for middle-class families. Sanders has said taxes would likely go up, while overall costs would drop. But Warren has resisted the question, arguing that admitting taxes would rise is equal to accepting a dishonest Republican framing of the issue. Warren has also attacked Buttigieg’s plan for failing to cover every American, dubbing it “Medicare for all who can afford it.”

“Your signature, Senator, is to have a plan for everything. Except this,” Buttigieg said at the debate. “No plan has been laid out to explain how a multi-trillion-dollar hole in this Medicare for All plan that Senator Warren is putting forward.”

Soon, Buttigieg will get his answer.

She ended your last weekend rally asking the “people” to give her a little more time and she will announce how she proposes to pay for it. More important, is her plan, probably an increase of taxes for all, including Middle Americans, to pay for it…. realistic???? Remember, nothing in any of the political “experts” proposals are ever free. Someone, you and I, have to pay for it in some way or another!!

Winners and losers in Medicare for All

There’s a very unpleasant collectivist feel to this. It’s all very well to say you can’t make an omelet without breaking some eggs … unless you’re the egg. About 56% of Americans — more than 180 million — have private health insurance through an employer. Medicare for All would sweep that all away, whether the people who have that insurance like it or not, in the name of the common good. Perhaps worse, as Warren knows perfectly well but steadfastly refuses to admit, there are going to be winners and losers. Costs might go down in the aggregate, but individuals and families aren’t aggregates.

Elizabeth Warren’s choice: ‘Medicare for All’ purity or a path to beating Trump?

For example, Warren keeps saying that the total you pay for health care would end up being less under Medicare for All because it will eliminate out-of-pocket costs like premiums and copays. That’s an oversimplification at best, especially since she hasn’t said how she would finance this enormously expensive project.

But it is a given that everyone will pay higher taxes, and it’s older people who spend more on premiums and out-of-pocket health care costs — a lot more. Consequently, older people will be far more likely to see these higher taxes offset by a decrease in the cost of their health care. By contrast, younger people and families at healthier stages of their lives would still be paying new taxes but will see fewer benefits.

 Your Two-Minute Summary of Tuesday’s Democratic Medicare-for-All Debate

Tuesday night’s Democratic presidential debate once again highlighted the candidate’s deep divides over Medicare for All. After opening questions related to the House impeachment inquiry into President Trump, the debate quickly turned to the health care reform plan backed by Senators Elizabeth Warren and Bernie Sanders.

Warren again tried to reframe the question of whether she would raise middle-class taxes to pay for the plan. “Costs will go up for the wealthy. They will go up for big corporations. And for middle-class families, they will go down,” she said. “I will not sign a bill into law that does not lower costs for middle-class families.”

Pete Buttigieg, who last month called Warren “extremely evasive” on the tax question, pounced. “No plan has been laid out to explain how a multi-trillion-dollar hole in this Medicare for all plan that Senator Warren is putting forward is supposed to get filled in,” he said, touting his “Medicare for All Who Want It” proposal as a better alternative. “I don’t understand why you believe the only way to deliver affordable coverage to everybody is to obliterate private plans, kicking 150 million Americans off of their insurance in four short years,” he said to Warren. “Why unnecessarily divide this country over health care when there’s a better way to deliver coverage for all?”

Warren jabbed back at Buttigieg, saying his “Medicare for All Who Want It” plan is really “Medicare for All Who Can Afford It.”

Joe Biden and Amy Klobuchar, both of whom support building on the Affordable Care Act with a public option, also attacked Medicare for All as expensive and impractical. “The difference between a plan and a pipe dream is something that you can actually get done,” Klobuchar said. “And we can get this public option done.”

Sanders defended his plan — and opened the door for further attacks on Warren. “At the end of the day, the overwhelming majority of people will save money on their health care bills,” Sanders said. “But I do think it is appropriate to acknowledge that taxes will go up. They’re going to go up significantly for the wealthy. And for virtually everybody, the tax increase they pay will be substantially less than what they were paying for premiums and out-of-pocket expenses.”

Klobuchar took the opportunity to criticize Warren again. “At least Bernie is being honest here, and saying how he’s going to pay for this and that taxes are going to go up,” she said. “And I’m sorry, Elizabeth, but you have not said that, and I think we owe the American people to tell them where we will send the invoice.”

A political strategy: The attacks on Warren are widely seen as a sign that she’s now the Democratic frontrunner — and they’re likely a sign that, as tiresome as the repeated tax question might get, Warren is going to keep getting asked it by the media, Democratic rivals, and Republicans. She’s pointedly not willing to answer directly (or take the bait) and say that she will raise taxes, even as she continues to argue that overall costs under Medicare for All will go down for the middle class. Her caginess on the question suggests she thinks that higher taxes on the middle class, or the very word “taxes,” might be toxic in an election campaign against Trump. But her dodging hasn’t hurt her so far.

What the polls say: The latest Kaiser Family Foundation tracking poll found that 51% of those surveyed favor Medicare for All, while 47% oppose it. A majority of Democrats and about half of independents support a national Medicare-for-all plan, while more than 70% of Republicans oppose the idea. Support for a public option is higher, at 73%. A CBS News poll released Tuesday found that 59% of voters believe that a government-run plan should “compete with private insurance” as under a public option, while 32% said they would want it to replace private insurance. But polls have also found that support for Medicare for All or other health plans can shift significantly depending on the arguments presented.

The bottom line: Larry Levitt of the Kaiser Family Foundation reminds us that there is no simple answer to the question of ultimate costs, and that a wide variety of outcomes are possible depending on how Medicare for All is implemented. “A Medicare for all plan could be designed so that many people, including those who are middle class, pay less in taxes than they are paying now in premiums, deductibles, and copays,” Levitt tweeted Tuesday. “It depends entirely on the details.”

J&J Pulls Baby Powder From Market

FDA testing reveals chrysotile fibers in one lot of embattled product of the J&J babypowder, which the courts are suggested cause ovarian cancer.

John Gever the managing editor of the MedPage reported that Johnson  & Johnson is recalling one lot of its famous baby powder because of possible asbestos contamination, the FDA announced Friday.

“FDA testing has found that a sample from one lot of the product contains chrysotile fibers, a type of asbestos,” the agency said in a press release. “Consumers who have Johnson’s Baby Powder lot #22318RB should stop using it immediately and contact Johnson & Johnson for a refund.”

Although Johnson & Johnson agreed to initiate the recall, it stopped short of admitting that the product really was contaminated. It questioned “the integrity of the tested sample and the validity of the test results,” suggesting that it might not even be a genuine Johnson & Johnson product.

The company has consistently denied that its baby powder — on the market for more than a century — has ever been contaminated with asbestos, but the company has faced numerous lawsuits from consumers alleging that they or loved ones developed cancer because of asbestos in talc components. The baby powder is popular not only for use on babies; many women have used it to reduce “feminine odors” as well.

The FDA said it has tested some 50 cosmetic products since 2018 for asbestos contamination, including two lots of Johnson’s Baby Powder. One was negative and the other was positive. This lot of baby powder is not the first to test positive and the FDA has previously issued alerts on others.

“The FDA expects to issue the full results from this survey, including all tested products having both positive and negative results, by the end of the year,” the agency said.

 

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