Medicare Scams Busted!

Ninety-Four Arrested Over Medicare Scams Totaling $251 Million.
ABC World News (7/16, story 6, 2:05, Muir) reported on "hundreds of raids carried out this country" on Friday "in what's being called the biggest Medicare fraud bust in history. Doctors and nurses billing the American taxpayer for procedures that never happened, and clinics that don't even exist."
The CBS Evening News (7/16, story 3, 2:00, Couric) noted that "one way the government plans to pay for healthcare reform is by cracking down on Medicare fraud. ... Dozens of people have been arrested including doctors, patients, and clinic owners accused of scamming Medicare out of hundreds of millions of dollars."
The AP (7/17, Kennedy, Hays) reported, "Authorities said busts carried out this week in Miami, New York City, Detroit, Houston, and Baton Rouge, La., were the largest Medicare fraud takedown in history." The move also was "part of a massive overhaul in the way federal officials are preventing and prosecuting the crimes."
The Washington Post (7/18, Markon) noted, "The arrests came as Attorney General Eric H. Holder, Jr. and Health and Human Services Secretary Kathleen Sebelius held the first in a series of regional 'summits' on healthcare fraud prevention in Miami. The high-level attention marked the latest step in crackdown on fraud that the Obama administration has said is a key part of its agenda on healthcare reform."
The Miami Herald (7/17, Hiaasen) pointed out, "Experts say Medicare fraud in South Florida costs US taxpayers between $3 billion and $4 billion annually. It's predictable that Miami-Dade, Broward and Palm Beach counties would be the hotbed, and also the venue for one of every three federal healthcare fraud prosecutions."
CNN.com (7/16) reported, "The defendants are charged with conspiring to submit over $280 million in false claims to the federal healthcare program designed to aid the elderly." Sebelius said, "Today's arrests send a strong message that attempts to defraud Medicare will not be tolerated." According to the report, "charges include filing fraudulent claims for HIV/infusion services, home healthcare, physical therapy and durable medical equipment."
The New York Daily News (7/17, Marzulli) reported, "The feds busted a Medicare mill in Brooklyn where the elderly gathered in a 'kickback room' to collect payoffs under a Cold War-era poster warning them to keep their mouths shut." Brooklyn US Attorney Loretta Lynch said yesterday "that 15 people were arrested -- including an 82-year-old woman. Seven others are being sought in the $78 million scheme." The Wall Street Journal (7/17, Benoit, subscription required) and CQ HealthBeat (7/17, Adams, subscription required) also covered the story.

Senior Rebate Checks for Medication

The Modesto Bee -Jun. 28: Seniors who regularly take expensive medications are starting to receive $250 checks from the federal government in one of the first tangible benefits of national health care reform.The Medicare prescription drug rebate checks are part of the health care law signed by President Barack Obama in March. The package of benefits, consumer protections and insurance reforms promises major changes to health care in the next 10 years.
Seniors in Stanislaus County have received some of the 80,000 Medicare prescription drug rebates mailed thus far. There is no need for seniors to apply for the rebates. The patient's drug plan notifies Medicare when his or her drug costs exceed $2,830 for the year and the check goes out, said Frank Dotson, director of the county's Health Insurance Counseling and Advocacy Program."They don't need to do anything," Dotson said. "And they don't need to report the rebate if they feel it will affect their eligibility for any other benefits they have."Look out for scam artistsSeniors should beware of scam artists purporting to help them apply for or spend the rebate checks, he added. More than 380,000 Californians struggle with the coverage gap in Medicare prescription plans. It starts when their drug costs reach $2,830 and then they are expected to pay full price for drugs until out-of-pocket expenses total $4,550 for the year.Dotson said many Medicare recipients with limited incomes are not taking advantage of a prescription-drug subsidy program that predated health care reform.The benefit eliminates annual deductibles and the coverage gap, and sharply reduces co-payments for seniors with income of $1,354 a month and less than $12,510 in assets. For couples, the eligibility ceiling is income of $1,821 a month and $25,010 in assets.

Rate Increases are Studied Before Approval

The Los Angeles Times (7/1, Helfand) reports, "Embattled health insurer Anthem Blue Cross is reviving its plan to raise rates for tens of thousands of California policyholders, some of whom could see their premiums rise as much as 20%." The state's "largest for-profit insurer submitted new rates Wednesday amid pressure to scale back increases of as much as 39% that had provoked fury from consumers, lawmakers and even President Obama." Meanwhile, "California Insurance Commissioner Steve Poizner has hired an actuary to study rate filings submitted by Anthem, Aetna, Inc. and Blue Shield of California. Poizner announced Wednesday that he was making the filings public on the insurance department's website," and "a fourth insurer, Health Net, Inc., also will undergo additional scrutiny once it files new rates."
The San Francisco Chronicle (7/1, Colliver) notes that the proposed rates "would raise health premiums by an average of 14 percent, and as much as 20 percent, for thousands of California consumers."

High-Risk Pools in CA to Obtain Federal Subsidies

In a NAHU Briefing update to agents on Health Care Reform I have noted that the High Risk Pool for CA will now have federal subsidies to help those who have been declined for health plans the opportunity to afford and enroll in the High-Risk plans though the State.

"California Lawmakers Approve Bills To Create High-Risk Pools.
The AP (6/29, Bussewitz) reports, "The California Legislature has narrowly passed two bills that will enable the state to obtain $761 million in federal subsidies to help thousands of uninsured Californians to obtain health insurance." Notably, the "bills enact federal health care reform changes and would create a high-risk pool for people who have been denied health insurance because they have pre-existing medical conditions."

Small Group Employers and Health Care Reform Updates

The Washington Post (6/15, Hilzenrath, Aizenman) reports, "If you like your health plan, you can keep it. That's what President Obama promised during the long months of debate over health-care reform," and the new rules issued on Monday are meant "to fulfill that promise." The Post adds, "The administration estimates that many plans will end up changing, prompting Republicans to accuse the president of breaking his word."
According to the AP (6/15, Alonso-Zaldivar), "The Obama administration had a message Monday for employers who want to keep federal bureaucrats from rewriting the rules for their company medical plans: Don't jack up costs for workers, and you won't have to worry about interference from the new health care law." HHS Secretary Kathleen Sebelius, who made the announcement, said, "What we don't want is a massive shift of costs to employees." The AP points out that this "new regulation that spells out how health plans that predate the health overhaul law can avoid its full impact."
For instance, the "regulations empower the administration to revoke the so-called grandfather status of businesses that shift 'significant' new burdens onto employees -- a considerable penalty that would subject those plans to all the consumer protections in the Democrats' new healthcare reform law," The Hill (6/15, Lillis) notes. Under these new rules, Sebelius said, "employers can make 'routine and modest' adjustments to their premium, deductible and co-pay requirements," although "'significant' cost hikes or benefit cuts would cost them their exempted status. The goal is to ensure that grandfathered plans 'don't use this additional flexibility to take advantage of their customers,'" she added.
Kaiser Health News (6/15, Galewitz, Carey) reports, "Business groups gave mixed reviews Monday to new Obama administration rules limiting how much employers and insurers can change their health insurance plans -- while remaining exempt from potentially costly new consumer protections." Notably, "consumer groups praised the regulations, saying the rules would ensure that millions of Americans receive the full benefits of the new health-overhaul law." In contrast, "business groups that opposed the enactment of the health overhaul law denounced the regulation." Randel K. Johnson, a senior vice president at the U.S. Chamber of Commerce, stated, "Once grandfathered status is lost, employers will be forced to follow a number of expensive new insurance rules -- which will increase costs for employers and employees, threatening the coverage Americans currently have."
Reuters (6/15, Charles) notes that investors and analysts are paying close attention to these new rules, as well as to the others being issued as health reform is being implemented, in order to determine their impact on the health insurance industry. The USA Today (6/15, Kiely) "The Oval" blog also covers the story.

Federal Government Cutting Funds to Medicare Program

The States are all reporting in and on the record as saying that cuts to medicare funding will help cause an unfavorable chain of events! Here is what Senate Majority Leader is doing about it:

Reid Working To Restore Medicaid Funds In "Extenders" Bill. CQ Today (6/8, Rubin, subscription required) reports, "Senate Majority Leader Harry Reid wants to undo a cut in aid to states that the House made to a tax and benefits bill that the Senate is scheduled to consider this week." Notably, "the House passed the bill (HR 4213) last month after paring it to satisfy members concerned about its cost. Reid, D-Nev., said Monday that he wants to put back billions of dollars of funding designed to help states cope with higher Medicaid costs during the recession." This "bill would also revive expired tax breaks, extend expanded unemployment insurance through Nov. 30 and prevent a scheduled payment cut to doctors under Medicare through 2011."

Patient Lifestyles increase Health Care Services Usage and In Turn Drive Costs Up

 Patient lifestyles — Increasing numbers of patients who are challenged by obesity, smoking, drug abuse, poor nutrition and physical inactivity contribute to an increase in the use of, and therefore the cost of, health care services.8 These preventable risk factors9 can also contribute to chronic diseases, which account for 75% of the money spent on health care in the U.S. each year.10
 Obesity — The percentage of obese adults now exceeds the percentage of healthy weight adults.
 Tobacco use — One in five adults smoke.
 Sedentary lifestyle — Less than one-third of adults report getting regular exercise.
 Poor nutrition — One in six adults has high cholesterol

-Anthem Blue Cross