HEALTH COACH - UnitedHealth Overbilled Medicare by Billions, the United States say in costume

HEALTH COACH - 
 UnitedHealth Overbilled Medicare by Billions, the United States say in costume  

 He stated that reviewing patient charts and correcting errors was "an appropriate and expected part of the Medicare Advantage program," and that questions about these activities "reflect at most a political disagreement" 
 
 
 

How Medicare Payments Work 


The traditional Medicare program reimburses physicians directly for the procedures they perform, but this can promote unnecessary treatment and inflate costs. For example, Medicare Advantage has been set up differently: the government contracts with for-profit insurers to manage health care for the elderly and pays insurers an annual fee for each member they enroll . This tax is higher for patients recently treated for certain conditions, creating an incentive for Medicare Advantage insurers to seek diagnoses of disease in their patients, even if none exist. 

 














 CENTERS FOR 

 MEDICARE AND 

 MEDICAID SERVICES 







  1. Traditional members of Medicare  pay a monthly premium to the centers for Medicare and Medicaid (C.M.S.) services, whether or not they have consulted a physician. C.M. Also receives funds from US taxpayers. 



  2.  If members see a doctor, the doctor sends a copy of their medical report to C.M., to be paid. 



  3.  C.M. Pay the doctor. Medicare traditional compensates doctors according to the procedures they perform - laboratory tests, analyzes, operations, etc. 








 CENTERS FOR 

 MEDICARE ET 

 MEDICAID SERVICES 







  1. Members of Medicare Advantage  also pay a monthly premium to C.M. and often a separate premium to a private insurance company. 



  2.  If members see a doctor, the doctor sends a copy of the medical report to the private insurer, who pays the doctor. 



  3.  C.M. Pay to the private insurer a basic rate for each member. If the private insurer tells C.M.S. That the member needed treatment for certain conditions, C.M.S. Pay more insurer. 










  1. Traditional members of Medicare  pay a monthly premium to the centers for Medicare and Medicaid services (C.M.S.), whether or not they have consulted a physician. C.M. Also receives funds from US taxpayers. 



  2.  If members see a doctor, the doctor sends a copy of their medical report to C.M., to be paid. 



  3.  C.M. Pay the doctor. Medicare traditional compensates doctors according to the procedures they perform - laboratory tests, analyzes, operations, etc. 










 CENTERS FOR 

 MEDICARE ET 

 MEDICAID SERVICES 




  1. Members of Medicare Advantage  also pay a monthly premium to C.M. and often a separate premium to a private insurance company. 



  2.  If members see a doctor, the doctor sends a copy of the medical report to the private insurer, who pays the doctor. 



  3.  C.M. Pay to the private insurer a basic rate for each member. If the private insurer tells C.M.S. That the member needed treatment for certain conditions, C.M.S. Pay more insurer. 











 CENTERS FOR 

 MEDICARE ET 

 MEDICAID SERVICES 












 
 "We are confident that our company and its employees have complied with the government's Medicare Advantage program," he said. 
 
 In filing his complaint on Tuesday, the Department of Justice joined in a whistleblowing lawsuit filed earlier by a former UnitedHealth Finance Director, Benjamin Poehling, who worked in the 2002 to 2012. Mr. Poehling filed his suit in 2011 under the False Claims Act, a law that allows private citizens to sue on behalf of government agencies that they believe have been defrauded. Such trials are usually kept under seal by the court at the outset, to allow law enforcement officers to investigate the allegations silently. 
 
 Mr. Poehling's trial was made public in February when the Department of Justice announced that it had decided to join its litigation. 
 
 Both trials are aimed at recovering money for Centers for Medicare and Medicaid Services, or CMS, the federal agency that administers Medicare, the program that provides medical coverage to people over 65 years old. If the dispute succeeds, Mr. Poehling would get a Percentage of Recovery. 
 
 The litigation relates to Medicare Advantage, a 14-year program that allows Medicare beneficiaries to obtain their health coverage from private insurers rather than from the government. When Congress established Medicare Advantage, lawmakers expected insurers to use the principles of care management to reinvigorate the 52-year Medicare program, resulting in better health care at lower cost For taxpayers. 
 
 One of the major changes has been the payment system: the government is paying insurers a predetermined amount for each person they enroll in Medicare Advantage, rather than paying doctors and To hospitals fees for each service provided. And to prevent insurers from registering only healthy people, the government agreed to pay them more for unhealthy people. How much more depends on a complex system of "risk rating", established by Medicare. 
 
 This is the problem, says the trial of the Ministry of Justice. "This payment model creates powerful incentives for insurers to exaggerate the healthcare costs expected for their members," he said. 
 

 

Document 


Complaint from the Department of Justice against UnitedHealth 


The Department of Justice filed a lawsuit against UnitedHealth Group, claiming that executives knew the company was covering a Medicare supplement of hundreds of millions of dollars annually. The ministry is associated with a whistleblower filed previously by former UnitedHealth Finance Director Benjamin Poehling. 



 




OPEN Document 




 
 Mr. Poehling's complaint stated that UnitedHealth and other insurers were using sophisticated data mining programs to search for people whose risk scores could be increased by adding new ones Diagnostic codes. As Chief Financial Officer of UnitedHealth's Medicare & Retirement Unit, he was expected to monitor the resulting revenue increases. 
 
 He stated that these initiatives have found little or nothing to find errors in the system that worked in the other direction: inaccurate Diagnostic Codes that, if corrected, would reduce payments. 
 
 "UnitedHealth's graphical evaluation program gave him all the information he needed to identify and remove hundreds of thousands of false statements that he had previously submitted," said Tim McCormack, Lawyer for Constantine Cannon, representing Mr. Poehling. "United has broken the law by ignoring this information and keeping the money". 


 The complaint of the Ministry of Justice said much the same thing. 
 
 To illustrate the problem, it included a list of examples of diagnostic coding errors that would have reduced UnitedHealth's revenues if they were corrected. They come from data that UnitedHealth itself collected in a quality control program that ran from 2011 to 2014, and then stopped. 
 
 An unnamed patient has been described to Medicare as having metastatic cancer, acute leukemia and unspecified stroke, for example, although these diagnoses have not been confirmed by the patient's charts. This invalid claim cost the government $ 24,380 in 2011, and there were hundreds of thousands of dollars more, the complaint said. 
 
 The Department of Justice stated that Medicare Advantage insurers are required to make good faith efforts to submit accurate and complete data to Medicare and if they only corrected errors in their favor, they were at variance. 
 
 Mr. Burns disagreed with this. He stated that Medicare had first proposed the rule "watching both ways" in 2014, but that it removed it. 
 
 
 

The price of risk 


The Medicare Advantage program pays insurance companies an annual fee for each person they register. And it pays more for people who are sick, to prevent insurers from rejecting them because their care will cost more. The practice, called "risk adjustment," gives insurers an incentive to tell the government that people are sicker than they may be. 

 







 

 

 MEDICARE ADVANTAGE PROGRAM 






 ADDITIONAL PAYMENT TO THE INSURER FOR SELECTED CONDITIONS 



 Diabetes without complications 




 Chest, prostate and other 

 cancers and tumors 




 Diabetes with acute complications 






 Major depressive, bipolar and 

 paranoid disorders 




 Lung and other severe cancers 




 Metastatic cancer and acute leukemia



"Yet the Ministry of Justice asserts that the rule existed all along," he said. "That makes no sense."


Errors compiled by the Department of Justice have not been corrected, according to the complaint, as they were found as part of a short-term quality control program To UnitedHealth. It started in 2011, with a reserve set up to hold the money that could be returned to Medicare one day: $ 208 million for overpayments for 2012 and up to $ 180 million for 2013 and $ 175 million for 2014.


The delay followed the delay and there was still money in the reserve in April 2014, when senior executives of the insurer realized that second quarter revenues of the company Were down $ 500 million from the budgeted amount. The detailed slides of an internal presentation showed that senior executives saw the accounting bookkeeping reserve as a place to get $ 250 million, in order to narrow the income gap to half, according to complaint.

But the company executives were concerned about the legal consequences of resuming the money allocated to the reimbursement of health insurance, mainly because the agency had Recently proposed a rule requiring insurers to "look at both ways" by checking the accuracy of their diagnostic codes.

In the end, UnitedHealth closed The quality control program anyway, according to the complaint. He did not correct the invalid diagnoses, and he moved the money from the reserve to the income.


Leaders, including UnitedHealth's executive head, Stephen J. Hemsley, have wanted money to narrow the income gap, the Department of Justice said.

"This was important for all, because they wanted to represent to the investors that the actual revenues of UnitedHealthcare Medicare & Retirement were on target," the complaint said. That the company's reported results in 2014 benefited from a single political shift ", which investors are unaware of."


Mr. Burns, the spokesman, said that the episode was "totally unrelated to the question of what this case is, and it is not clear C.M.S. Policy. "

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