Increased Government Control of Health Care Will Increase Fraud, Corruption and Abuse
Missing from President Barack Obama's health care program pitch last night was the likelihood that increased government control will also mean increased fraud, corruption and abuse of the system.
Last night, millions of Americans watched President Barack Obama sell his national health care plan on nationwide television. The reporters during the televised question and answer portion of Obama's performance attempted to appear unbiased, but their tone and demeanor was a marked difference from the attack approach they use on conservative politicians. And not one reporter asked about the potential for fraud and corruption in such a huge financial endeavor.
With the Obama Administration and Democrat leaders in both houses of the US Congress desperately pushing a major overhaul -- many say government takeover -- of US health care, a report obtained by the National Association of Chiefs of Police's Fraud & White Collar Crime Committee sheds light on the fraud and corruption already existing in government medical programs. And one can only imagine the amount of corruption that will occur with total government control of the medicine,
On April 22, 2009, Government Accountability Office officials testified before an ad-hoc Congressional subcommittee at a hearing entitled, "Eliminating Waste and Fraud in Medicare and Medicaid." 
In a subsequent letter responding to a May 29, 2009 request for responses to questions for the record related to the April 22, 2009, testimony, the GAO responded to the following questions: What do you see as the biggest challenge for Centers for Medicare/Medicaid Services (CMS) to provide an estimate for improper payments under Medicare Part D? Has GAO identified any problems with the current process for reviewing and paying Medicare claims that would make the program more vulnerable to fraudulent claims? Is there any reason the US federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program cannot include penalties in its Medicare Administrative Contractor contracts for paying improper or fraudulent claims that they are aware of?
With total outlays of about $46 billion in fiscal year 2008, Medicare Part D is the last significant part of Medicare for which the department has yet to develop an estimate of improper payments. In developing its estimate, it will be important for CMS to determine where the vulnerabilities and risks exist in the Medicare Part D structure and operations that could impact CMS's ability to effectively detect, measure, and ultimately reduce improper payments.
In HHS's fiscal year 2008 AFR, the department reported that it had calculated payment error rates for two components of Medicare Part D but also that its measurement was not fully implemented. Also, it will be important to consider Health and Human Services' Office of Inspector General identified concerns about CMS's implementation of internal controls to ensure payment accuracy as well as inadequate analysis of claims data.
The GAO investigation identified several weaknesses with the current process for reviewing Medicare claims. Limitations in the number of medical reviews conducted leave the home health benefit -- within the Medicare program -- vulnerable to improper payments, including payments resulting from fraud and abuse.
In previous studies, the GAO reported in February 2009 that in fiscal year 2007, only 0.5 percent of the more than 8.7 million home health agency (HHA) claims processed were subjected to prepayment review by Medicare's contractors.
The contractors focused primarily on claims submitted by HHAs whose billing patterns differed from their peers on measures such as cost per episode. Of those claims that were reviewed, over 40 percent were denied in whole or in part. There are also weaknesses with respect to selecting claims to review in Medicare Fee-for-Service.
In addition to the weaknesses with the current Medicare claims review process, analysts found that failure to effectively screen health providers before granting them billing privileges also increases the program's vulnerability to fraudulent claims.
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Consistent with the Social Security Act and applicable federal procurement regulations, CMS may include provisions in Medicare Administrative Contractor (MAC) contracts to: prescribe the costs incurred by MACs in processing and paying Medicare claims that CMS may reimburse; provide incentives or disincentives related to payment accuracy; and hold MACs and their employees liable for improper or fraudulent claims payments under limited circumstances.
Otherwise, neither the Social Security Act nor applicable federal procurement regulations expressly provides for CMS to reduce amounts owed to MACs under their contracts or to assess charges against MACs for improper or fraudulent claims payments.
Opponents of the plan currently considered by the US Congress -- commonly known as ObamaCare -- believe that if the US government succeeds in taking control of the health care industry, losses due to fraud and abuse will drastically increase.
He's former chief at a New York City housing project in Washington Heights nicknamed "Crack City" by reporters covering the drug war in the 1980s. In addition, he served as director of public safety at a New Jersey university and director of security for several major organizations. He's also served on the National Drug Task Force and trained police and security officers throughout the country. Kouri writes for many police and security magazines including Chief of Police, Police Times, The Narc Officer and others. He's a news writer for TheConservativeVoice.Com and PHXnews.com. He's also a columnist for AmericanDaily.Com, MensNewsDaily.Com, MichNews.Com, and he's syndicated by AXcessNews.Com. He's appeared as on-air commentator for over 100 TV and radio news and talk shows including Oprah, McLaughlin Report, CNN Headline News, MTV, Fox News, etc.
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Comments
It's a wonder the AMA and all doctors aren't up in arms over nationalization of their profession. Don't they know back in the old USSR, a doctor would receive the same wages as a potato grower. They should watch "The Unbearable Lightness of Being," and see how a brain surgeon became a window washer for criticizing the regime.
Here's a side-note on the same issue and I believe, although it isnt exactly fraud, it's one of the reasons Medicare costs have gone thru the roof: it's medical equipment that's overpriced and often not necessary. Case in point-the CPAP 'cartel' is now setting up clinics in senior citizen complexes to test seniors for 'sleep apnea'. . a very ambiguous standard. That's because Medicare now pays for the units at the cost of several thousand each. Many people have to try several units before they find one they can tolerate. These things are nothing more than a glorified fish tank aerator with a humidifier attached. The manufacturers and purveyors of these things are making a mint. Check the stock reports on them. Then, they have to be monitored-at a price-and have filters, etc replaced. People have to be retested and the unit replaced regularly. All for people in their eighties who never knew they had a problem before the test. It's a scam against the taxpayers AND the elderly!
Well BR, in my life I've relied more on a potato picker than a brain surgeon along with 99% of the population...what does that tell you?
Blue Cross expenses, to administer the medical plan I am on, have been going up by 10 to 30 percent per year over the last 10 years. This is independent of the actual claims experience or medical costs. Is this any better than the government would do? Private insurance cartels are not efficient except at generating oversize wages to execs and salesboys who add no value to the process.
They also interfere in medical decisions by deciding which treatments are justified for payment, independently of the doctors judgement. Is this any better than government deciding?
It would take effort for the government to be less efficient, more wasteful or more dictatorial than the faceless, greedy insurance bureaucrats. And it would get the useless salesboys and their excessive commissions for lying, out of the equation.
BR ... it's assh++es like you with forethought of an ant that will keep the U.S. healthcare delivery system in the dark ages. The AMA is the 2nd most powerful union in the US to the ABA. Get a mouth filter.
Oh, Stu, you have me ROFWL! Yeah, let's just get rid of them all. Besides, potatoes, potassium-rich, are much healthier than all their drugs. We can heal ourselves, thank you very much, AMA and Obama.
For eight years the BUSH administration did nothing about waste, fraud and abuse in Medicare. Spending for program integrity activities did not increase one dollar even though claims volumne went up 300 million claims, a Part D program was added and there was an expansion in managed care. The system also allows any willing provider, meaning that if you meet the basic definition you can open a healthcare company. Every dollar spent on program integrity activities in medicare saves 7. A massive investiment in program integrity activities would reap rewards in savings.
Yes -there will be fraud---I knmow abpit <edocare fraud first hand-My Mother was in the Nursing home and I had the "Advice of settlements" sent to my home- I checked and questioned charges on each one.She had a primary Doctor but other docters were involved-I could not find them in the phone book in Jackson TN- Why would a Dr drive 35 miles to check a patient when there was no need? She had severe dementia but a phycharist checking her? Absurb- I have a stack of these settlements which is10 to 12 miches high.If I could have found these quacks - I would have sued. they they facked up $80 here - $125 her etc-enough in the 7 years to retire in the south of France, I'll bet.
i use to work for a home healthcare.i really loved working in this field until i started working with another company. the company is so different,they want to pay you salary at (725)bi-weekley.you're working four clients, but they are cheating people out of there money.they tell you that you're not gonna work all the hours just go in and do what they want u to do then u can leave,but they are still getting paid from the government the full amount.some of the worker are working for 2 other companys, you can't be at 2 places at the same time. to top the whole thing they have there kids on their payroll. they're all fofself.thats why all healthcare homecares need to properly checked. now they are trying to do an appeal so i want get my bennifits
Your article is both misleading and false. After a decade of ignoring the growing problem of medicare fraud, the Obama administration has directed HHS and the FBI to crack down on these crooks. Medicare fraud task forces have been created in Miami, the intellectual center of the crime, along with a number of other cities. The health care reform bill proposed by the White House includes a number of provisions to help law enforcement agencies attack these crimes. So, enforcement nationwide has gone from lackadaisical to energetic and new laws to help enforcement are included in the reform bill, yet you write that if the bill passes "losses due to fraud and abuse will drastically increase."
Again, your article is simply misleading and wrong.
Your figures on Medicaid fraud are incorrect.
Even the NYS OMIG has downgraded their estimate of the fraud to 3% of claims which is also probably high. An examination of OMIG takebacks in NY in one service area, suggested that only 10% of the monies recouped from providers was actually fraud. The rest were errors most of which were errors where services were provided but where claims were denied because of record keeping technicalities.
It's one thing to take exception to the Obama plan but your case should be made with more accurate information.
Time to leave this country.
I am studying to become a Medical Claims Examiner and I participate by communicating on the White House blog about the new medical electronic records changes. It is hard for me to envision a lot of medicare/medicaid fraud under the conditions which are required of me in the academic setting at Gatlin Education and Edward Shands Adult School in order to achieve certification in the field.
Selling out of the Poor? What would Elmo say?
Full Name: Wayne Berman Title: Vice-Chair; Finance Co-Chair; Adviser
Over the course of three years, Berman’s lobbying firm was paid $660,000 to lobby on behalf of UnitedHealth subsidiary Americhoice, a managed care HMO providing health insurance to Medicaid, Medicare, and SCHIP recipients. Specifically, according to the lobbying report, they lobbied on Medicaid issues in the Deficit Reduction Act of 2005.[Americhoice Lobbying Reports 2004 – 2007; Americhoice.com ] Berman Also Lobbied For “Absurdly Low” Rates for Medicaid Managed Care Companies to Pay Out of Network Hospitals. Also included in the DRA, and mentioned as a lobbying issue on Berman’s Americhoice lobbying report, was a provision setting rates managed care companies must pay to out-of-network providers -- mainly hospital emergency rooms -- for care received by Medicaid beneficiaries. Rather than forcing managed care companies to reimburse out-of-network hospitals an amount comparable to network providers, the legislation set the default amount to the state’s “fee-for-service rate,” which often is “absurdly low.” The provision thereby shifted financial responsibility for services to Medicaid beneficiaries from the managed care companies to the hospitals themselves, permitting managed care companies to rake in huge profits, while hospitals incurred added losses.[Modern Healthcare, 1/29/07; Text of S. 1932] To Save Money, Bill Cut Services to Medicaid Beneficiaries, But Left Managed Care Providers Untouched. Under the final budget package, substantial Medicaid spending cuts were achieved by imposing new premiums and increased co-payments on Medicaid beneficiaries; some costs were also shifted to the states, who in return were awarded new powers to drop coverage or reduce benefits to certain beneficiaries. In a letter to Senate Majority Leader Bill Frist, the AARP CEO decried the final bill, saying it “protects the pharmaceutical industry, the managed-care industry and other providers at the expense of low-income Medicaid beneficiaries.”[Inside CMS, 12/29/05; Los Angeles Times, 12/22/05; World Markets Analysis, 12/21/05; The Hill, 12/20/05]
The Players and whats up for grabs. Profits United Health Group 2010 $4.293 billion
Here are some other 2010 budget numbers: Wonder what it cost CMS ( Can't Manage Sxxx) to operate each year.$453 billion Medicare///$290 billion Medicaid ///$78.7 billion Department of Health and Human Services/// UnitedHealth Group Awarded TRICARE Managed Care Support Contract ... Jul 13, 2009 ... UnitedHealth Group Awarded TRICARE Managed Care Support Contract for more than $20.3 billion. BILLIONS awarded and still to be awarded United's AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice's revenue rose 34% last year, to $6 billion. United Health Group and its subsidiarys must be exhausted from signing Corporate Integrity agreements each and every year and as reward for their violations well what happens? they are awarded more contracts and more money and maybe even an ambassadorship here and there and if anybody should question what the heck is going on, then send them a Elmo doll.(Americhoice sponsors Sesame Street) Up side, Billions to be made, down side pay some fines (cost of doing business) move on and nobody goes to jail or gets excluded from the game. Get up the next day put on your Elmo costume and its back to work as usual. WOW, even in the Casino world or Mob world this would be a no no, suprised Hollywood has not done a movie on this or maybe even great TV.
The Government created this monster and now they don’t know what to do about it, like shooting yourself in your own foot etc.Tons of money to advance their national growth, its market positions, tons of money for political donations, tons of money to send 75 millon back to its home office from New York state alone, tons of money to suppot National TV shows, tons of money to pay hugh State fines, tons of money to hire the very best law firms, tons of money to pay for bribes and kickbacks, tons of money for hugh salarys and bonuses, all done on the back of the American taxpayor, you see this company receives all its money from the Federal State governments. Should your tax dollars it be held to a higher standard? Should the government agencys responsible for there review be held to that same standard? Should the IRS audit their corruption? Why has this company not been charged? How long can the buck be passed here in more ways then one?
Federal investigators fault CMS for poor oversight of Medicaid managed care contracts
By Julian Pecquet - 08/04/10 12:12 PM ET
A Government Accountability Office report released Wednesday finds the agency that oversees Medicaid approved managed care contracts that might not have met federal requirements. The report found regional gaps in oversight and in the data the states collect to ensure the rates insurance companies charge for the care of Medicaid beneficiaries are accurate. The top Democrat and Republican on the Senate panel that has jurisdiction over Medicaid immediately called on the Centers for Medicare and Medicaid Services to increase its oversight. "This report makes clear that we don’t have enough information to guarantee that prices are accurate and that Medicaid is protected," Finance Committee Chair Max Baucus (D-Mont.) said. "CMS has taken some steps to boost oversight, but this report makes clear that the agency needs to be more aggressive in its oversight of state contracts to ensure that care is coming at an accurate price. I intend to continue monitoring this issue to make sure that progress is being made and the Medicaid program is working effectively for Americans who need it. CMS has already made some changes as a result of the GAO’s findings, according to the senators, including requiring all regional offices to use a checklist when reviewing state’s rate-setting submissions. But they say more needs to be done.
"Medicaid could be overpaying in some cases and underpaying in others," said ranking member Chuck Grassley (R-Iowa). "CMS isn’t checking behind adequately to know either way. In a program that spends hundreds of billions of dollars, that’s a problem. Every dollar that goes to waste doesn’t help someone get healthcare. CMS needs to conduct much better oversight of the job states are doing with taxpayer dollars in the Medicaid program." The report raises questions with Medicaid contracts in two states in particular. Tennessee received $5 billion a year in federal funds for rates that had not been certified by an actuary, as required by federal regulations, the report says. And in Nebraska the Centers for Medicare and Medicaid Services (CMS) did not complete a full review of rate setting since new requirements became effective, leaving doubts as to whether they are in compliance.
United Health Group Defrauded 100 Million Americans Posted on January 13th, 2009 by iwaller
An investigation begun by New York’s Attorney General, Andrew Cuomo said the company Ingenix, a research firm owned by UnitedHealth Group deliberately shorted reimbursements on out-of-network health insurance claims for Americans to the tune of hundreds of millions of dollars! Ingenix claimed it relied on ‘independent research from across the health care industry’ to determine reimbursement rates. However, UnitedHealth Group and its company Ingenix manipulated the health care claims presented by millions of Americans having health insurance and shorted their reimbursements between 10% and 28% of what the coverage should have paid. Instead, UnitedHealth Group, pocketed the millions of dollars it shorted Americans. UnitedHealth Group provides health benefits to 26 million Americans. Nearly all health care insurance companies in the country were using the same low reimbursement rates. Some of the largest health insurance companies who utilize the same Ingenix system are United Health Care (owned by UnitedHealth Group), Aetna, Cigna, Wellpoint/Empire BlueCross BlueShield and Genix. These companies are currently under investigation in New York suspected of participating in the same reimbursement fraud. How ironic UnitedHealth Group’s mission statement says in part: “We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve…We work with health care professionals to expand access to high-quality health care so people get the care they need at an affordable price.” Rather than anyone going to jail, UnitedHealth Group settled with the New York Attorney General by agreeing to pay $50 Million as the settlement to be used to establish and create a new database to determine rates for patients who choose physicians outside of the insurance giant’s network. Little good this does for the millions of Americans who were ripped off by these insurance scumbags. “This is a huge scam that affected hundreds of millions of Americans [who were] ripped off by their health insurance companies,” says Cuomo. “This was unethical, and it robbed vulnerable patients of insurance reimbursements they deserved.” Cuomo is now investigating other insurance companies that use Ingenix’s database. There may be millions more on the line as well. Of course, as is the corporate way of the guilty, UnitedHealth Group stated “We respectfully disagree with the New York Attorney General’s findings that we manipulated data … (or that our ownership of Ingenix was a conflict of interest.) We agreed to his settlement because it was an effective way to address any perceived conflict of interest.” The American Medical Association, represented by Dr. Nancy Nielson, president-elect of the AMA stated “there is a profit motive for keeping reimbursement low.” ”It is shocking and unacceptable for an insurance company to hide behind a shroud of secrecy”. Nielson also said “It is another example of UnitedHealth playing by its own rules.” This is not the first time UnitedHealth has been involved in legal action. In 2000, the AMA filed a lawsuit in federal court in New York over the exact same reimbursement issues. In May of 2008, Oxford Health Insurance, Inc, a unit of UnitedHealth Group, had to refund $50 million to small business customers in New York to settle claims it overcharged for health insurance policies back in 2006. More trouble from the past, when former CEO, William W. McGuire, M.D. was charged with securities fraud by the SEC. Mr. McGuire ultimately found guilty, had to repay $468 million as a partial settlement of the prosecution. In summary, I am of the opinion that corporate America is as corrupt as anywhere on earth. CEO bilking millions in golden parachutes and executive compensation, while American citizens fund their luxurious lifestyles with hard earn money, simply to be overcharged, cheated and ripped off by the rich and powerful. The UnitedHealth Group scam, is no different that the crooks on Wall Street: AIG, Goldman Sachs, Morgan Stanley, Merrill Lynch, Lehman Brothers, Bear Stearns, Fannie Mae, Freddie Mac, Citigroup, and other corporate manipulators such as Shell Oil, Exxon-Mobile, and so many other financial and energy leading companies. The free market system is over in America, thanks to corporate greed which took its roots during the Reagan trickledown economic philosophy. Corporate America cannot and should not be trusted and the federal government is almost in the same boat. Disdain for hardworking Americans by the Wall Street and Corporate America is so prevalent, they no longer tried to hide. The ‘haves’ continues to increase the divide between the ‘have not’s. Americans, Republicans and Democrats, should be outraged and the raping and pillaging of their money by Corporate America. We must begin to demand a government that works with incorporating fines and bringing to justice those criminals who rob, steal and cheap on a national basis from hard working citizens. None of the men leading these companies have gone to jail. Where is the justice for middle American who pays the bills for these outlaws?
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