Connect with us

News

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

The company, which is the nation’s largest Medicare Advantage operator, denies wrongdoing and argues that the Justice Department “fundamentally misunderstands” how Medicare Advantage works.

Published

on

 

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.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Continue Reading
Click to comment

News

Middle schoolers have a plan to stop rock art tagging in Western Colorado

Published

on

Courtesy gjhikes.com

GRAND JUNCTION, Colo. (AP) — Arron Buehler’s day in a western Colorado canyon might not have had the Hollywood panache of Ferris Bueller’s day off, but something about seeing Buehler’s name scrawled on the sandstone escarpment gave Chris Joyner pause.

Joyner, spokesman for the Grand Junction Office of the Bureau of Land Management, looked at Buehler’s name — and those of many others emblazoned on rock in a canyon south of Grand Junction — and said that, paradoxically, there might be a reason for hope.

It was just last year that Buehler posted his name, next to Elizabeth, who left her mark in 2017.

Few of the names appeared to be more than a year or two old, and, “That tells me there’s opportunity here,” Joyner said.

The more recent the markings, the more likely the vandals are to be found, and the more likely it is that other methods might discourage younger people from following Arron Buehler’s lead, Joyner said.

Joyner and BLM archaeologist Alissa Leavitt-Reynolds are working in Grand Junction to deal with vandalism on federal lands, whether it be by graffiti artists such as Charley Humpy (who helpfully added, “Remember me” next to his name and yes, the BLM is doing all it can to achieve total recall), drug users ditching evidence in the desert, mayhem by “marksmen” and plain old dumping.

As much as Arron Buehler and a multitude of companions — Brian, Charley, Dizz, Dominique, Kay, Megan, Elizabeth, Jon, Sam and Tosha all seem to be begging for court dates (and Tosha, did you know your name covered an ancient petroglyph?) — Joyner said prosecution ought not be the only response to a growing trend of vandalism and worse on western Colorado’s rocky outcrops and arid landscapes.

Citations for vandalism aren’t tracked by the Colorado U.S. Attorney’s Office, which prosecutes offenses on federal land, so no precise numbers are available.

An Army veteran, Joyner is using his post 9/11 GI Bill funds at Johns-Hopkins University to study ways to divert people from what he terms “dysfunctional visitor behavior.”

“Dysfunctional visitor behavior” has a more authoritative ring than “vandalism” and “littering” and Joyner said he hopes that a scholarly approach can help agencies fend off some of the destructive activity on federal lands before it takes place.

Some of his research suggests that “informed participation in nearby historic and cultural sites” can influence the way many residents perceive those sites, Joyner said.

The students in Ginger DeCavitch’s social studies classes at Mount Garfield Middle School experienced “informed participation” last summer.

DeCavitch took her students into Bangs Canyon to see the mica mine and found the defaced escarpment “as we were stepping over broken beer bottles and charcoal” from fires.

Vandals had used charcoal to scratch names and slogans on the rock, DeCavitch said.

“They call it tagging” and few participants see any issue with defacing the rock, taking selfies and posting them on social media, DeCavitch said.

She contacted the BLM soon afterward to see if her class could help clean up the mess they found.

“They all wanted to go back,” enough that some students hauled 40-pound containers of water down an occasionally difficult trail to help clean the site, DeCavitch said.

Her middle school students sat silent as members of the Southern Ute tribe described how they perceived the canyon and the ancient markings, many of which had been defaced, DeCavitch said.

Far from being discouraged, her students were enthused about tackling the enormity of the defacement, DeCavitch said.

“We have a plan that we’ll be back,” she said.

Introducing young people properly to wild lands is one way to discourage future vandals and dysfunctional visitors.

It’s one “foot-in-the-door” tactic that Joyner hopes land managers take up.

Visitors also can be endowed with a sense of ownership by agreeing with a simple proposition — the idea that one ought not litter on public lands, for instance — and then be brought along to agree with how to visit them appropriately, Joyner said.

It’s part of a human tendency to want to be consistent, he said. People who agree not to litter tend to want to build on that as opposed to act in contradictory fashion, he said.

Even providing a small gift or trinket can engender a sense of responsibility among potential vandals, Joyner said.

Other techniques include the “broken-window” approach — the idea that replacing broken glass as soon as it’s found and thus denying miscreants their moment of victory — isn’t as easy as it might be in other environments, Joyner said.

DeCavitch’s class, for instance, learned that while cleaning up a mess might eliminate an eyesore, it also could erase history.

Her eager middle-schoolers couldn’t go forward with the cleanup until members of the Southern Ute Tribe, headquartered in Duchesne, Utah, approved the plan, DeCavitch said.

While Joyner’s studies have suggested that males 16 to 25 who live within 60 miles of Grand Junction are the likely offenders, one look at the escarpment suggests that young women are more active participants than crime statistics might suggest, Joyner said.

One study suggests that younger people prefer non-coercive approaches, but Joyner said that doesn’t mean the BLM is losing interest in prosecuting vandals and others.

Far from it.

BLM officials routinely contact school officials and consult high school yearbooks to match the names they come across with people who could be prosecuted.

Some miscreants make it easier, posting selfies of themselves with their works. Some even lower the level of difficulty by including hashtags.

The criminal exposure can reach felony levels because of the difficulty and expense of dealing with cleaning up or restoring the markings that date back hundreds of years.

If the malefactors are found, Joyner said, “We don’t write warning tickets.”

___

Information from: The Daily Sentinel, http://www.gjsentinel.com

Continue Reading

News

The #WhatNow of #MeToo for the #COLeg

Published

on

AP Photo/David Zalubowski

When several lawmakers, lobbyists and staff at the state Legislature came forward this fall to allege they were victims of sexual harassment by lawmakers, two big questions followed: how often does this happen? What can be done to prevent more cases?

Reporters have asked state officials the first question repeatedly, returning to readers with little response from the state. The latter prompted a conversation from leadership, but as for what’s next—how the allegations, formal complaints, and legislature’s response—will impact politics under the gold dome and whether women will feel any safer is to be determined.

So far, top state lawmakers have decided to hire a human resources officer—who would be independent from the legislature—to be a contact person when incidents involving sexual harassment are brought forward. Now, leadership is tasked with handling and investigating such claims.

The group also decided to hire an independent consultant to review the legislature’s sexual harassment policy, and lawmakers, staff, and aides will undergo another round of sexual harassment training this year. Typically, those working at the Legislature are only required to go through training every two years.

Those changes are a good start, said Erin Hottenstein, executive director of Colorado 50/50, an organization that aims to get more women in public office. But the legislature stopped short of changing any current policies. And Colorado 50/50 called for an entire overhaul.

“I’m very pleased that there was a recognition that the policy needs to be improved,” Hottenstein said.

But there weren’t any specific recommendations regarding transparency, which Hottenstein said is significant in looking at what happens next.

Lawmakers and staff said they couldn’t disclose how many sexual harassment claims that leadership in each chamber have received because they were personnel issues.

“I think there’s a way to be transparent and safe,” Hottenstein said. “There should be a high- level summary document that shows on a certain date a sexual harassment complaint was made and who it was against and a date of a deposition and what the result was.”

Hottenstein said transparency becomes crucial in these cases because it leads to accountability and the public’s right to know what actions the people elected to office are taking.

In October, Pueblo Rep. Daneya Esgar broke her silence posting on Facebook that she was no stranger to sexual harassment and experienced it just a week earlier with a colleague she works with regularly as a lawmaker. The post was part of the #MeToo movement after a New York Times expose highlighted the stories of several women who said they’d been sexually harassed or assaulted by Hollywood producer Harvey Weinstein.

Then, a flood of other allegations were brought to the surface in Colorado politics. Rep. Faith Winter said fellow House member Steve Lebsock had harassed her at a legislative party in 2016. Winter and a lobbyist say they filed formal complaints against Lebsock.

An intern said Sen. Randy Baumgardner harassed her with sexually suggestive comments. The same went for Sen. Jack Tate of Centennial, who was accused of telling an intern that if she wanted to get ahead in her career, he could help.

Rep. Paul Rosenthal, who is openly gay, allegedly groped a man and used his seat to try and get a date with another.

But the case between Lebsock and Winter gained the most attention, even prompting Lebsock to take a polygraph test, which the administrator says he passed, to prove his innocence. Lebsock has hinted that the entire incident may be a case of dirty politics, alleging that Winter is the one lying.

When several lawmakers were asked if the case would mean a splintered Democratic party in the House, they were unsure, but optimistic about the session.

Still, there haven’t been any resignations over the allegations, though several, including leadership and editorial boards from across the state, said these legislators should step down from their seat. Some even called for House Speaker Crisanta Duran to step down from her position because she promoted Lebsock to a chairmanship despite knowing there was an incident between him and Winter.

The transparency piece has yet to be addressed by state lawmakers, and it’s unclear whether any policy or legislative changes will address that in the coming months. But for what it’s worth, the women who have broken their silence about sexual harassment in the Legislature are supportive of the changes leadership has discussed.

“I’m encouraged to see the direction leadership is taking when it comes to developing new and independent methods of dealing with complaints of sexual harassment at the Capitol,” said Esgar, who still hasn’t named the colleague she said grabbed her thigh at a legislative event earlier this year. “I’m hopeful that new ideas are still being formulated and considered, when it comes to ways to change the culture itself.”

The lawmaker added that a new session will certainly mean new ideas will come to light, “it’s our responsibility to lead the state in changing cultures to help make work environments safe and productive for all employees on every level.”

Continue Reading

News

20 cities primed on the Amazon wishlist to be its next HQ

Published

on

NEW YORK (AP) — Amazon’s second home could be in an already tech-heavy city, such as Boston, New York or Austin, Texas. Or it could be in the Midwest, say, Indianapolis or Columbus, Ohio. Or the company could go outside the U.S. altogether and set up shop in Toronto.

Those six locations, as well as 14 others, made it onto Amazon’s not-so-short shortlist Thursday of places under consideration for the online retailing giant’s second headquarters.

The 20 picks, narrowed down from 238 proposals, are concentrated mostly in the East and the Midwest and include several of the biggest metro areas in the country, such as Chicago, Washington and Los Angeles, the only West Coast city on the list.

The Seattle-based company set off fierce competition last fall when it announced that it was looking for a second home, promising 50,000 jobs and construction spending of more than $5 billion. Many cities drew up elaborate presentations that included rich financial incentives.

The list of finalists highlights a key challenge facing the U.S. economy: Jobs and economic growth are increasingly concentrated in a few large metro areas, mostly on the East and West Coasts and a few places in between, such as Texas.

Nearly all the cities on Amazon’s list already have growing economies, low unemployment and highly educated populations.

“Amazon has picked a bunch of winners,” said Richard Florida, an economic development expert and professor at the University of Toronto who helped develop that city’s bid. “It really reflects winner-take-all urbanism.”

Among those that didn’t make the cut were Detroit, a disappointment for those excited about progress since the city came out of bankruptcy, and Memphis, Tennessee, where the mayor said the city gave it its “best shot.” San Diego also failed to advance.

“Getting from 238 to 20 was very tough,” said Holly Sullivan, who oversees Amazon’s public policy. “All the proposals showed tremendous enthusiasm and creativity.”

Amazon said it will make a final selection sometime this year.

Besides Austin, another Texas city made the cut: Dallas. In the South, Miami and Atlanta are being considered.

Officials in cities that made the shortlist took the opportunity to further tout their locations, with Philadelphia’s mayor noting “all that Philadelphia has to offer” and officials in and around Pittsburgh citing the region’s “world-class talent pool” and other advantages.

Other contenders among the 20 include Denver; Montgomery County, Maryland; Nashville, Tennessee; Newark, New Jersey; Northern Virginia; and Raleigh, North Carolina.

“It’s a long list for a shortlist,” said Jed Kolko, chief economist at job site Indeed.

He said Amazon may use the list to pit the locations against each other and get better tax breaks or other incentives. Two metro areas, New York and Washington, have more than one location on the list, increasing the competition there, he said.

“It’s hard to say whether all these places are in play or Amazon wanted to encourage continued competition,” Kolko said.

Amazon did not immediately respond to a request for comment on whether locations would be able to change their proposals or offer better incentives, but said in a statement that it will “work with each of the candidate locations to dive deeper into their proposals.”

State and local governments played up the amenities they think make their locations the best choice. Some pulled off stunts to stand out, such as New York, which lit the Empire State Building in Amazon orange.

Some gimmicks didn’t work: Tucson, Arizona, which sent a 21-foot cactus to Seattle, did not make the list. Neither did Birmingham, Alabama, which installed giant replicas of Amazon’s Dash buttons.

The company had stipulated that it wanted to be near a metropolitan area with more than 1 million people, and nearly all of those on the shortlist have a metro population of at least double that.

Amazon also wanted to be able to attract top technical talent; be within 45 minutes of an international airport; have direct access to mass transit; and be able to expand the headquarters to as much as 8 million square feet in the next decade.

But Amazon also made it very clear it wanted tax breaks, grants and any other incentives.

Boston’s offer includes $75 million for affordable housing for Amazon employees and others. Before leaving office Tuesday, Gov. Chris Christie approved a measure to allow New Jersey to offer up to $5 billion to Amazon. Newark is also proposing $2 billion in tax breaks.

But many of the state and local governments competing for the headquarters have refused to disclose the financial incentives they offered. Of the 20 finalists, 13, including New York, Chicago and Miami, declined requests from The Associated Press to release their applications. Toronto’s mayor said Thursday that the city offered no financial incentives to woo Amazon.

Several said they don’t want their competitors to know what they’re offering, a stance that open-government advocates criticized.

Amazon plans to remain in its sprawling Seattle headquarters, and the second home base will be “a full equal” to it, founder and CEO Jeff Bezos has said.

The extra space will give the rapidly growing company room to spread out. It had nearly 542,000 employees at the end of September, a 77 percent jump from the year before. Some of that growth came from Amazon’s nearly $14 billion acquisition last year of the Whole Foods grocery chain and its 89,000 employees.

____

Associated Press writers Josh Cornfield in Philadelphia, Matt O’Brien in Providence, Rhode Island, and Rob Gillies in Toronto contributed to this report. Rugaber contributed from Washington.

Continue Reading

Trending