Wednesday, May 24, 2017

United Healthcare Doctored Medicare Records, Overbilled U.S. By $1 Billion, Feds Claim


KHN



 

The Justice Department on Tuesday accused giant insurer UnitedHealth Group of overcharging the federal government by more than $1 billion through its Medicare Advantage plans.

In a 79-page lawsuit filed in Los Angeles, the Justice Department alleged that the insurer made patients appear sicker than they were in order to collect higher Medicare payments than it deserved. The government said it had “conservatively estimated” that the company “knowingly and improperly avoided repaying Medicare” for more than a billion dollars over the course of the decade-long scheme.

“To ensure that the program remains viable for all beneficiaries, the Justice Department remains tireless in its pursuit of Medicare fraud perpetrated by healthcare providers and insurers,” said acting U.S. Attorney Sandra R. Brown for the Central District of California, in a statement announcing the suit. “The primary goal of publicly funded healthcare programs like Medicare is to provide high-quality medical services to those in need — not to line the pockets of participants willing to abuse the system.”

Tuesday’s filing is the second time that the Justice Department has intervened to support a whistleblower suing UnitedHealth under the federal False Claims Act. Earlier this month, the government joined a similar case brought by California whistleblower James Swoben in 2009. Swoben, a medical data consultant, also alleges that UnitedHealth overbilled Medicare.

The case joined on Tuesday was first filed in 2011 by Benjamin Poehling, a former finance director for the UnitedHealth division that oversees Medicare Advantage Plans. Under the False Claims Act, private parties can sue on behalf of the federal government and receive a share of any money recovered.

UnitedHealth is the nation’s biggest Medicare Advantage operator covering about 3.6 million patients in 2016, when Medicare paid the company $56 billion, according to the complaint.

Medicare Advantage plans are private insurance plans offered as an alternative to traditional fee-for-service option.

Medicare pays the health plans using a complex formula called a risk score, which is supposed to pay higher rates for sicker patients than for people in good health. But waste and overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity concluded that improper payments linked to jacked-up risk scores have cost taxpayers tens of billions of dollars.

Tuesday’s court filing argues that UnitedHealth repeatedly ignored findings from its own auditors that risk scores were often inflated — and warnings by officials from the Centers for Medicare & Medicaid Services (CMS) — that it was responsible for ensuring the billings it submitted were accurate.

UnitedHealth denied wrongdoing and said it would contest the case.

“We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with CMS about our approach under its unclear policies,” UnitedHealth spokesman Matt Burns said in a statement.

Burns went on to say that the Justice Department “fundamentally misunderstands or is deliberately ignoring how the Medicare Advantage program works. We reject these claims and will contest them vigorously.”

A spokesman for CMS, which has recently faced congressional criticism for lax oversight of the program, declined comment.

Central to the government’s case is UnitedHealth’s aggressive effort, starting in 2005, to review millions of patient records to look for missed revenue. These reviews often uncovered payment errors, sometimes too much and sometimes too little. The Justice Department contends that UnitedHealth typically notified Medicare only when it was owed money.

UnitedHealth “turned a blind eye to the negative results of those reviews showing hundreds of thousands of unsupported diagnoses that it had previously submitted to Medicare, according to the suit.

Justice lawyers also argue that UnitedHealth executives knew as far back as 2007 that they could not produce medical records to validate about 1 in 3 medical conditions Medicare paid UnitedHealth’s California plans to cover. In 2009, federal auditors found about half the diagnoses were invalid at one of its plans.

The lawsuit cites more than a dozen examples of undocumented medical conditions, from chronic hepatitis to spinal cord injuries. At one medical group, auditors reviewed records of 126 patients diagnosed with spinal injuries. Only two were verified, according to the complaint.

The Justice Department contends that invalid diagnoses can cause huge losses to Medicare. For instance, UnitedHealth allegedly failed to notify the government of at least 100,000 diagnoses it knew were unsupported based on reviews in 2011 and 2012. Those cases alone generated $190 million in overpayments, according to the suit.

While Medicare Advantage has grown in popularity and now treats nearly 1 in 3 elderly and disabled Medicare patients, its inner workings have remained largely opaque.

CMS officials for years have refused to make public financial audits of Medicare Advantage insurers, even as they have released similar reviews of payments made to doctors, hospitals and other medical suppliers participating in traditional Medicare.

But Medicare Advantage audits obtained by the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit show that payment errors — typically overpayments — are common.

All but two of 37 Medicare Advantage plans examined in a 2007 audit were overpaid — often by thousands of dollars per patient. Overall, just 60 percent of the medical conditions health plans were paid to cover could be verified. The 2007 audits are the only ones that have been made public.

CMS officials are conducting more of these audits, called Risk Adjustment Data Validation, or RADV. But results are years overdue.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Categories: Health Industry, Medicare

Tags: Medicare Advantage

fschulte@kff.org | @fredschulte


Tank You Mr Schulte and KHN. 

Tab For Single Payer In California Could Cost $400 Billion

KHN

 
A proposed single-payer health system in California would cost about $400 billion annually, with up to half of that money coming from a new payroll tax on workers and employers, according to a state analysis.


The report by the state Senate Appropriations Committee, issued Monday, put a price tag for the first time on legislation that would make the state responsible for providing health coverage to all 39 million Californians. The state-run system would supplant existing employer health insurance in California, as well as coverage through public programs such as Medicaid and Medicare.

One of the chief obstacles to the legislation, Senate Bill 562, is the prospect of higher taxes. It also has exposed deep divisions among Democrats over whether now is the time to pursue single-payer — just as the Affordable Care Act comes under attack from Republicans in Washington. At a hearing Monday, one Democratic legislator questioned whether the state can effectively manage a universal health care system.

The legislative analysis estimates a total annual cost of $400 billion to enact the Healthy California program for all residents, regardless of their immigration status. Use Our Content
This story can be republished for free (details).

To put that in perspective, about $367 billion was spent on health care last year statewide, including public and private spending by employers and consumers, according to the UCLA Center for Health Policy Research.

Legislative analysts said federal, state and local taxpayer funding of about $200 billion a year for existing programs could be available to offset the overall tab of $400 billion for universal coverage. But additional tax revenue would be needed to foot the other half of the cost, according to the report, which raised the possibility of a 15 percent payroll tax on earned income.

Of course, the shift to a single-payer system should reduce current spending on health insurance by employers and workers, so those savings could offset some of the new taxes, the analysts said. The report estimated that employers and employees in California spend $100 billion to $150 billion a year now on health insurance and medical care.

“Total new spending required under the bill would be between $50 billion and $100 billion per year,” the report said.

The Senate analysis noted that all of its projections were “subject to enormous uncertainty” because the bill would mark “unprecedented change in a large health care market.”

A single-payer system likely “would be more efficient in delivering health care,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (California Healthline is produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.)

But the proposal expands coverage to all and eliminates premiums, copayments and deductibles for enrollees, and that would cost more money, Levitt said. “You can bet that opponents will highlight the 15 percent tax, even though there are also big premium savings for employers and individuals,” he added.

State Sen. Ricardo Lara (D-Bell Gardens), a chief sponsor of the legislation, said the present system is unsustainable because health spending continues to grow faster than the overall economy, making coverage unaffordable for too many people.

Lara touted the potential savings from creating a public plan with greater bargaining power and cutting out the administrative overhead and profits of private health insurers acting as middlemen.

Overall, many of the details behind California’s single-payer proposal remain in flux. Under questioning from fellow lawmakers, Lara said the 15 percent payroll tax is “hypothetical” and “we don’t have a financing mechanism yet for this bill.”

Lara said he has sought a review from researchers at the University of Massachusetts-Amherst into potential funding sources for the measure.

Lara also said there’s no guarantee the Trump administration would grant the federal waivers necessary for California to shift Medicare and Medicaid funding into a single pot for universal health care.

With so many unknowns, the Senate Appropriations Committee didn’t vote on the measure Monday. Backers of the legislation are hopeful for a vote in the full Senate next month and then lawmakers could continue to work on the financial aspects during the summer.

At Monday’s hearing, many consumers pointed to Medicare as a model for how single-payer works now and urged lawmakers to make California the proving ground for how it can succeed at the state level.

Business groups and health insurers spoke out in opposition, saying it would lead to massive disruption and escalating costs. Even if it passes the legislature, California Gov. Jerry Brown hasn’t endorsed the idea and new taxes may require a statewide ballot measure, which are always hard-fought campaigns.

The California Chamber of Commerce said the costs would likely be far higher than what was projected and the taxes imposed on employers would trigger major job losses.

State Sen. Jim Nielsen (R-Tehama), a member of the Appropriations panel, expressed similar concerns. “The impact on employers will be astounding,” Nielsen said. “How can you say this will be fiscally prudent for the state? The state has never gotten anything right in health care.”

State Sen. Steven Bradford (D-Gardena) also preached caution, questioning whether state agencies are up to the task. “I don’t want California to move toward a program that is not sustainable and one that we can’t manage,” Bradford said.

Other states have taken a close look at single-payer and balked. Colorado voters rejected a ballot measure last year that would have used payroll taxes to fund a near-universal coverage system.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Insurance, States

Tags: California State Assembly, Legislation

cterhune@kff.org | @chadterhune



Thank You Mr Terhune and KHN. 

Putting A Lid On Waste: Needless Medical Tests Not Only Cost $200 Billion -They Can Do Harm





It’s common knowledge in medicine: Doctors routinely order tests on hospital patients that are unnecessary and wasteful. Sutter Health, a giant hospital chain in Northern California, thought it had found a simple solution.

The Sacramento-based health system deleted the button physicians used to order daily blood tests. “We took it out and couldn’t wait to see the data,” said Ann Marie Giusto, a Sutter Health executive.

Alas, the number of orders hardly changed. That’s because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system — but, as the Sutter example illustrates, it’s often not as simple as it seems.

Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

“The changes that need to be made don’t appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland, Calif., nonprofit group that promotes quality improvement. “We’ve been patient for too long.”

In California, that sense of frustration has led three of the state’s biggest health care purchasers to band together to promote care that’s safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange and the state’s Medicaid program, known as Medi-Cal — which collectively serve more than 15 million patients — are leading the initiative.

Progress may be slow, but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests by more than 10 percent by educating both doctors and patients about overuse.

A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery. As a result, patients on average received the surgery six months sooner.

These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to determine whether they truly need a procedure.

Critics have knocked Choosing Wisely for playing it too safe and not going after some of the more lucrative procedures, such as certain spine operations and arthroscopic knee surgeries.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful at starting a national conversation about unwarranted care. “I think we need massive change and that takes 15 years,” Wolfson said.

The state effort, dubbed Smart Care California, is in the early stages as well.

Initially, the group has focused on cutting the number of elective cesarean sections, reducing opioid use and avoiding overtreatment for patients suffering low-back pain. In its contract with health insurers, the Covered California exchange requires that their in-network providers meet a range of quality standards, including low C-section rates.

Dr. Richard Sun, co-chairman of the Smart Care group and a medical consultant at CalPERS, said he’s pursuing safer, more affordable treatments for low-back pain, a condition that cost the state agency $107 million in 2015. “One challenge is developing metrics that everyone can agree upon to measure improvement,” he said.

For patients, overtreatment can be more than a minor annoyance. Galen Gunther, a 59-year-old from Oakland, said that during treatment for colorectal cancer a decade ago he was subjected needlessly to repeated blood draws, often because the doctors couldn’t get their hands on earlier results. Later, he said, he was overexposed to radiation, leaving him permanently scarred.

“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility for that.”

At Cedars-Sinai Medical Center in Los Angeles, officials said that economic incentives still drive hospitals to think that more is better.

“We have excellent patient outcomes, but it’s at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery at Cedars-Sinai. “There is still a continued financial incentive to do that test, do that procedure and do something more.”

In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head.

To cut down on needless care, Cedars-Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that run contrary to 18 Choosing Wisely recommendations.

The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in 6 percent of those cases, or 1,591 encounters.

Sax said Cedars-Sinai studied the rate of complications, readmissions, length of stay and direct cost of care among the patients in whose cases the guidelines were followed and compared those outcomes with cases where adherence was less than 50 percent.

In the group that didn’t follow the guidelines, patients had a 14 percent higher incidence of readmission and 29 percent higher risk of complications. Those complications and longer stays increased the cost of care by 7 percent, according to the hospital.

In 2013, the first year of implementation of Choosing Wisely guidelines, Cedars-Sinai said it avoided $6 million in medical spending.

For perspective, Cedars-Sinai is one the largest hospitals in the nation with $3.3 billion in revenue for the fiscal year ending June 30. It reported net income of $301 million.

In Northern California, Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said, it has saved about $66 million since 2011.

That’s a significant sum. However, during the same period, Sutter reported $2.7 billion in profits. Last year alone, it posted an operating profit of $554 million on revenue of nearly $12 billion.

Giusto said her team of employees tasked with changing physician behavior and eliminating these variations is separate from administrators who are focused on maximizing reimbursement. She said there can be conflicting forces within a hospital.

“We get real excited about a project with [emergency department] doctors on reducing CT scans for abdominal pain,” said Giusto, director of Sutter’s office of patient experience. “Then I can hear the administration say that was a fee-for-service patient. I just lost money, right?”

Giusto meets with doctors to present data on how many tests or prescriptions they order and how that compares to others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time while others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.

“Most of the physicians changed,” Giusto said. “But there were still two who said, ‘Screw it. I’m going to keep doing it.’”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: Cost and Quality, Health Industry

Tags: Electronic Health Records, Hospitals


Thank You Mr Terhune and KHN.

Jazz Break: Bill Connors: Step It

It's a playlist, so keep clicking through it, top left corner.

Tuesday, May 23, 2017

2017 Has Seen A Terror Attack Attempted In Europe Every 9 Days


weaselzippers
 


London mayor, Sadiq Khan says terror attacks ‘part and parcel’ of living in a major city.

Via Breitbart:

Europe, the United Kingdom, and Russia have witnessed terror attacks or attempted attacks every nine days in 2017 on average, analysis of security incidents has revealed.

Since January, around 45 people have been killed by mostly Islamic terrorists, while hundreds have been injured. The only known incident not linked to jihadism in 2017 was the attack on the Borussia Dortmund soccer team by a Russian-German national attempting to profit from short-selling stock in the company.

Attacks and attempted attacks have taken place in Austria, France, the United Kingdom, Belgium, Italy, Russia, Sweden, Norway, and Germany.

Security services in Britain — population 65 million — are known to be tracking 3,500 potential terror suspects or persons posing a threat. Meanwhile Belgium, with its population of just 12 million, is tracking around 18,000 potential jihadists.

A further minimum of 14 terror attacks have occurred in Turkey in 2017, a NATO member country currently being considered for European Union membership.

Europe, the United Kingdom, and Russia have witnessed terror attacks or attempted attacks every nine days in 2017 on average, analysis of security incidents has revealed.

Keep reading…

Thank You Breitbart and Huck Funn.

Youngest Victim In Manchester Terror Attack Was 8 Years Old

weaselzippers



Horrific.
Via Daily Mail:

Eight-year-old victim Saffie Roussos has been described as ‘simply beautiful’.
Chris Upton, the headteacher of her school, Tarleton Community Primary, said: ‘The thought that anyone could go out to a concert and not come home is heartbreaking.’
It continued: ‘Saffie was simply a beautiful little girl in every aspect of the word. She was loved by everyone and her warmth and kindness will be remembered fondly. Saffie was quiet and unassuming with a creative flair.
‘Our focus is now on helping pupils and staff cope with this shocking news and we have called in specialist support from Lancashire County Council to help us do that.
‘We are a tight-knit school and wider community and will give each other the support that we need at this difficult time.’

Thank You Nick and Daily Mail. 


"Mere tolerance is the virtue of a man who no longer believes in anything."

G.K. Chesterton.

Homeless Man Had To Pull Nails Out of A Little Girl's Face After Manchester Attack


dailycaller
Russ ReadPentagon/Foreign Policy Reporter
1:13 PM 05/23/2017


A homeless man who rushed to help the victims of Monday’s terrorist attack on the Manchester Arena said he had to “pull nails” from children’s bodies and faces.

The man, identified only as “Steve,” recounted the harrowing scene to Britain’s ITV news Tuesday. He noted that many of victims were young children covered in blood.

“It’s just instinct to go and help, if someone needed your help and it was children and it was a lot of children with blood all over them and crying and screaming,” Steve said. “We were having to pull nails out of their arms, and a couple out of this little girl’s face.”


‘We had to pull nails out of children’s faces’: Steve, a homeless man who was sleeping near #Manchester Arena, rushed to help young victims pic.twitter.com/dyxzZpal0Q

— ITV News (@itvnews) May 23, 2017

Steve noted how he and a friend had to hold one victim’s legs up to prevent her from bleeding out after discovering a cut on her side. He said that just because he is homeless, it doesn’t mean he doesn’t have a “heart.”

Two explosions rocked the arena as concert goers were leaving an Ariana Grande concert Monday night, killing 22 and injuring approximately 50 others. The attacker reportedly detonated his payload outside a ticket kiosk, waiting for the concert to end in apparent attempt to maximize casualties. The use of nails, screws and ball bearings as shrapnel is a hallmark of jihadi terrorist groups.

The Islamic State took responsibility for the attack on Tuesday, saying a “caliphate soldier managed to place a number of devices among a gathering of crusaders in Manchester, and detonated them.”

U.S. officials suspect 22-year-old Salman Ramadan Abedi was responsible for the attack, according to several reports.

Steve noted that he felt it was his responsibility to aid those hurt in the attack.

“It had to be done, you had to help. If I didn’t help, I wouldn’t be able to live with myself for walking away and leaving kids like that,” he said.

Follow Russ Read on Twitter

Send tips to russ@dailycallernewsfoundation.org.

Thank You 'Steve. Mr Read and DC.

Trump's Budget Eliminates Funding For U.N. Global Warming Programs

dailycaller
Michael Bastasch
3:13 PM 05/23/2017



The Trump administration has proposed eliminating nearly $1.6 billion in international programs aimed at promoting green energy and fighting global warming.

That includes providing no funding to the United Nations’ Green Climate Fund (GCF), which hands out money for programs to adapt or mitigate global warming.

The White House said this proposal is in line with President Donald Trump’s campaign pledge to “cease payments to the United Nations’ climate change programs.” The budget “fulfills that pledge,” according to budget documents.

The Obama administration gave nearly $1 billion to the GCF in 2016. The Trump administration proposed eliminating that funding, along with zeroing out funding for three other climate programs.

The budget also withdraws funding for the Clean Technology Fund and the Strategic Climate Fund for a savings of $239 million. It would also stop funding the Global Climate Change Initiative, saving taxpayers $362 million.

“America must put the energy needs of American families and businesses first and continue implementing a plan that ensures energy security and economic vitality for decades to come, including by promoting development of the Nation’s vast energy resources,” White House budget documents read.

Trump promised to “cancel” UN global warming payments while on the campaign trail. Trump also promised to withdraw from the Paris climate agreement, which the Obama administration joined in 2016.

“We’re spending hundreds of billions of dollars. We don’t even know who’s doing what with the money,” Trump said in November.

Trump’s budget makes good on that promise, and Congress is likely to go along with these cuts.

On the other hand, Trump has yet to make a decision on whether or not he’ll keep his promise to pull out of the Paris Agreement.

The White House is split on the issue. European governments and multinational corporations have lobbied the administration to stay in the Paris agreement, which they say may fall apart without U.S. involvement.

Trump is expected to make a decision on Paris this week.



Thank You President Trump, Mr Bastasch, and DC. 


Climate Depot's New 'Talking Points' Report - A-Z Debunking of Climate Claims