Who knew Miami was the Medicare fraud capital of the country? An enormous net of Medicare malfeasance was cast, involving over 100 nurses, physicians, and executives colluding to nab over a quarter of a billion dollars from the feds — topping a July ’10 bust in that and other regions.
Special Agent in Charge John Gillies said Medicare should conduct comprehensive criminal background checks on providers, stop the practice of paying claims within 14 days, suspend payments for questionable charges, and change the system of using Social Security numbers for beneficiaries to prevent identity theft.
No truer (or more obvious) words will be spoken about this problem. You can also add to that: reining in the extremely dynamic nature of CMS oversight of criteria for payment, establishing strict criteria for contractors which are involved in payment processes and audit recoveries, and shoring up reporting processes to include specific state agencies (IG offices, for example) in order to streamline signal from noise. Of course, naked publicity of the nature surrounding this story always helps.
By the close of 2010, the Obama administration had hoped that roughly 375000 healthcare consumers would take advantage of the national high-risk insurance pool, known as the government’s Pre-existing Condition Insurance Plan, but enrollment is falling far short of projections. The coverage is meant as a bridge to 2014, when it will be mandated — effectively outlawing discrimination based upon that coverage. HHS is at loss to explain, but the agency is launching a website today to inform. This is a somewhat interesting development because, previously, the administration really never promoted the program. The sudden desire of HHS to do so says more about reaction to GOP efforts at their plans for reform, as opposed to the administration’s initial push for universal coverage under reform.
Essentially, the fed program is an alternative to an expansion of high-risk pools with higher deductibles and premiums which the GOP is proposing to fund over the next 10 years. At this point, the goal of both sources of high-risk pooling appears to be the same. Even with the increased awareness of the federal PCIP program, it’s a little difficult to envision a sharp increase in potential enrollees, as the CBO estimates that the program will have a hard time cracking the 1M enrollee threshold by 2014. | LINK
States are now able to ask for even more in grants to help fund insurance exchanges that are a critical provision to the reform law. HHS Secretary Sebelius related in a recent conference call that the funds are of no specific amount and that most states have already received at least $1M in planning grants each.
The exchanges are to be functional by the 2014 cycle in reform. They are designed, as directed by the ACA, to allow families, individuals, and small businesses for instance, to negotiate an insurance marketplace for the most affordable coverage possible via lowered premium costs. The move to increase grant funding for this purpose comes right on the heels of GOP House repeal of the law.
California’s fiscal woes continue to mount; from significant budgetary shortfalls on the government’s end, to the anger felt by consumers on the cost of living as it relates to the affordability of healthcare. The state’s troubles with the federal government, private insurers, providers, and patients as healthcare consumers alike are well documented and have led to promises of cost-saving reforms in care delivery.
But, wait. Apparently, one insurer continues to test the regulatory reach of California’s insurance commission. BC/BS plans to hike premiums by another third over two recent hikes. This could lead to a total hike in premiums of approximately 60 percent by the middle of the year for some healthcare consumers. Unfortunately, the insurance commissioner does not have the legal authority to block excessive premium increases under CA law.
Blue Shield of California has shocked its policyholders with a proposal to raise premiums by as much as 59 percent, effective March 1. The San Francisco-based company says the higher rates are needed to cover fast-rising costs. It’s the second time in less than a year that a California health insurer has asked for a whopping increase. Last year, Anthem Blue Cross drew sharp criticism from the Obama administration after requesting a 39 percent rate hike. Anthem Blue Cross ultimately settled for a 20-percent hike.
Blue Shield has released a statement that the rate hikes are unrelated to the Affordable Care Act and notes that the rate hikes in California are due to increased medical costs. | LINK
HHS is issuing guidelines on the process of reviewing rate increases of insurers. The federal government is requiring any insurer seeking a premium rate increase of at least 10 percent to file justification for the increase with state commissions and the feds, as well.
The federal government does not have the power to reject the proposed increase outright, however. The goal here seems to be transparency, as HHS will post such information on its website for public consumption. The regulation, part of reform, will undergo a public review for six months prior to implementation. | LINK
UPDATE: Some private insurers are upset that certain vendors — ones that also function as major industry lobbying arms — are unfairly “protected” under these new Obama reform law initiatives, as some supplemental coverage plans under Medicare (Medigap plans) will escape scrutiny at the expense of private plans in the healthcare marketplace which may augment rates commensurate with market forces. | LINK
Key players in the current administration’s push for elimination of fraud and abuse in healthcare delivery are meeting today in Mass. during what is billed as a day-long “summit” on the issue. Perhaps the two biggest Obama surrogates in attendance are Atty. Gen. Eric Holder and HHS Sec’y. Kathleen Sebelius.
Engineered as part of an overall plan to eliminate Medicare fraud, the meeting is one of many regional conferences set up nationwide to address the ongoing problem. Panels including law enforcement , consumer experts, health care providers and federal, state and local government agencies will take part. | LINK
On Monday the Obama administration finally released the rules governing the spending of Big Insurance. The details of the fate of the medical loss ratio — the percentage of Insurance’s revenue which is dedicated to administrative costs versus the amount paid out in coverage — constitute that rare reform provision giving cautious optimism to patients, their advocates, and insurance companies alike.
Healthcare consumers benefit from the increased coverage payouts,[1] as do those who seek this type of advocacy under reform. And Insurance — through some fancy footwork on their part[2] — are able to achieve MLR cut-offs more easily, affecting profit margins less.
State insurance commissioners are also on board, as the new rules will enhance insurers’ transparency in this space — making it easier for regulation in a volatile short term while the latter begin to apply these new processes. | HHS fact sheet LINK
Unsurprising, but still worth noting.
The U.S. Supreme Court on Monday rejected a long-shot request for a review of the Obama administration’s health-care overhaul before the matter has been fully litigated.
The appeal the Supreme Court rejected Monday was unusual because the plaintiffs wanted the justices to hear their case even though a lower U.S. appeals court hasn’t yet ruled on the matter.
The high court almost never hears cases before they have been fully litigated in the lower courts, and it hadn’t asked the Obama administration to file legal papers responding to the appeal.
No appeals court has ruled, although federal judges have had varying rulings in different regions of the country on the case, Baldwin v. Sebelius.
This is a surprise. Well, at least I wasn’t expecting this aspect of reform to initiate so quickly: five states will be awarded grants to fund tech infrastructure for the purpose of creating early insurance exchanges. HHS, of course, is responsible for the project’s implementation. The hope is that a template will be created for the overall adoption of the exchanges by mid-decade, as the result of reform.
President Obama’s push for IT integration into all aspects of reform is at play here, as interested states competing for the lucrative grants will have to design seamless modes of technology foundations for the exchanges. The amount that the states will receive is yet to be determined, with the announcement of finalists and grant recipients by February ’11.
Call Kathleen Sebelius & company anything but guilty of misappropriating federal funds here. The GAO has ruled that the recent promotional ad campaign, which used very elderly actor Andy Griffith in its spots, did not inappropriately use government funds by overstating reform’s Medicare benefits. The standards of publicity and propaganda were not breached as part of the campaign, according to the non-partisan body. HHS had paid over $3M to fund the advertising — characterized, in part, by spots in which Griffith called Medicare improvements under reform “music to my ears”.
GAO also examined three television ads featuring Griffith. It found that they did not constitute “covert communications,” “self-aggrandizement” or “purely partisan activities,” which are prohibited.
The GAO ruling appears to be a setback to the House Committee on Oversight and Government Reform, as its government-wide jurisdiction and expanded legislative authority make it one of the most influential and powerful committees in the House. The setback could be temporary, however, pending the results of the expected shift in the balance of power in the November elections and its impact on the evolution of the reform law over the first half of the ’10s.
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
