Tag Archives: Medicare

AI Fraud could target America’s most vulnerable communities like Medicare and Social Security with criminals operating all over the world

Revelations 13:14 “…by the signs that it is allowed to work in the presence of the beast it deceives those who dwell on earth…”

Important Takeaways:

  • AI-assisted fraud schemes could cost taxpayers $1 trillion in just 1 year, expert says
  • Artificial intelligence smashed the floodgates to unprecedented fraud that could cost taxpayers hundreds of billions, if not $1 trillion, over the next 12 months, an expert told Fox News Digital.
  • Haywood Talcove, CEO of LexisNexis Risk Solutions’ government division, which evaluates and predicts risk, said he’s already seeing criminals on the dark web using people’s faces to steal from government and state agencies.
  • Benefits to America’s most vulnerable communities, such as Social Security, Medicare and Medicaid, and unemployment, are ending up in the pockets of criminals and criminal enterprises that are operating all over the world.
  • “Being one of the wealthiest countries in the world makes us a huge target,” Talcove said. “The amount of money that we’re going to lose over the next 12 months, if we do nothing, is going to make the COVID pandemic look like child’s play.”

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Trump administration issues two rules aimed at drug prices

(Reuters) – U.S. President Donald Trump on Friday said it was issuing two new rules that are aimed at lowering drug prices for the Medicare program, including one aimed at making sure pharmacy benefit managers pass after-market rebates onto seniors.

The second rule is aimed at aligning the prices paid in the United States to those paid in foreign countries, he said.

(Reporting by Caroline Humer, Editing by Franklin Paul)

Walmart to sell Medicare plans in latest healthcare push

(Reuters) – Walmart Inc said on Tuesday it would sell Medicare insurance plans in 50 states and Washington D.C. through its broker, marking the U.S. retailer’s latest move into the healthcare space.

Walmart Insurance Services LLC, which was launched in July, will offer policies from health insurers such as Humana Inc, UnitedHealth Group and Anthem Blue Cross Blue Shield from Oct. 15-Dec. 7, the company said.

Medicare Advantage plans cater to Americans older than 65 and those with disabilities.

The company already operates health centers across the United States, offering low-cost services such as dental care and counseling.

Walmart’s move comes at a time when health insurers face rising costs as Americans catch up on less urgent surgeries delayed by the COVID-19 pandemic.

Hospitals rescheduled elective surgeries to reduce the burden on the healthcare system as coronavirus cases surged, while some patients canceled appointments to avoid potential contraction of the respiratory illness caused by the virus.

(Reporting by Noor Zainab Hussain in Bengaluru; Editing by Ramakrishnan M.)

Black Americans hospitalized for COVID-19 at four times the rate of whites, Medicare data shows

(Reuters) – Black Americans enrolled in Medicare were around four times as likely as their white counterparts to be hospitalized for COVID-19, U.S. government data released on Monday showed, highlighting significant racial disparities in health outcomes during the pandemic.

“The disparities in the data reflect longstanding challenges facing minority communities and low income older adults,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), which released the data.

The data showed that more than 325,000 Medicare beneficiaries were diagnosed with COVID-19 between Jan. 1 and May 16. Of those, more than 110,000 were hospitalized.

Black Americans had a hospitalization rate 465 per 100,000 Black Medicare beneficiaries. For other groups measured by CMS, the rates of per capita hospitalizations were 258 for Hispanics, 187 for Asians and 123 for whites.

Hospitalization rates were high for people who qualified for both the senior-focused Medicare program and the low-income-focused Medicaid program, at 473 per 100,000.

“Low socioeconomic status all wrapped up with racial disparities represents a powerful predictor of complications with COVID-19,” Verma said during a briefing about the data.

Medicare beneficiaries with end-stage kidney disease were hospitalized for COVID-19 at a rate of 1,341 per 100,000.

Medicare is a federal health insurance program designed primarily for seniors, as well as some people with disabilities and end-stage kidney disease.

Verma said that CMS’ ongoing push to reimburse providers based on health outcomes rather than paying them fixed fees for their services could help address racial disparities.

“When implemented effectively, (value-based reimbursement) encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life,” Verma said.

The data is based on claims filed for reimbursement from Medicare and therefore operates at a delay of several weeks.

(Reporting by Trisha Roy and Carl O’Donnell; Editing by Shinjini Ganguli and Cynthia Osterman)

U.S. watchdog finds $6.7 billion in questionable Medicare payments to insurers

By Chad Terhune

(Reuters) – A U.S. government watchdog is raising fresh concerns that health insurers are exaggerating how sick Medicare patients are, receiving billions of dollars in improper payments as a result.

Health insurers selling Medicare Advantage plans to seniors and the disabled received an estimated $6.7 billion in 2017 after adding diagnoses to patients’ files that were not supported by their medical records, according to a report released on Thursday by the U.S. Health and Human Services (HHS) Inspector General’s Office.

Inspectors found that Medicare Advantage insurers had added diagnoses for diabetes, heart disease and other conditions in 99.3% of chart reviews of patient information, even though they did not appear in records from doctors, hospitals or other medical providers. Insurers deleted incorrect diagnoses less than 1% of the time, they found.

The additional diagnoses boosted government payments to insurers by an estimated $6.9 billion, while the deleted information trimmed payouts by nearly $200 million, producing a net benefit of $6.7 billion for the companies.

“We could not see any services with the diagnosis and that raised a number of concerns,” Linda Ragone, a regional inspector general in Philadelphia and co-author of the report, said in a phone interview. “There is a vulnerability here that needs to be addressed.”

The report highlighted a group of 4,616 Medicare Advantage enrollees for whom insurers added a diagnosis that resulted in a higher payment, even though there was no record of the person receiving any medical services during the year under review.

Medicare Advantage plans are privately-run alternatives to traditional Medicare. They served 22 million people – or 1 in 3 of those eligible for the government healthcare program – at a cost of $210 billion in 2018.

The report did not identify specific insurers. UnitedHealth Group Inc <UNH.N>, Humana Inc <HUM.N> and CVS Health Corp <CVS.N> through its ownership of Aetna, are among the biggest sellers of Medicare Advantage plans. Together, the three companies have 54% of the market, according to the Kaiser Family Foundation.

America’s Health Insurance Plans (AHIP), an industry trade group, said the rate of improper payments in the Medicare Advantage program has been decreasing.

“Everyone agrees that Medicare Advantage payments must be fair and accurate, and we continue to work with (Medicare) to improve payment accuracy,” said AHIP spokeswoman Kristine Grow.

The U.S. government pays Medicare Advantage insurers based on a risk score for each enrollee. The formula pays more for sicker patients, creating a financial incentive for insurers to inflate risk scores.

The U.S. Centers for Medicare and Medicaid Services (CMS) should be doing more to prevent insurers from exploiting this vulnerability, the inspector general said.

In a Nov. 1 letter to the inspector general’s office cited in the report, CMS challenged the $6.7 billion estimate of payments linked to chart reviews as too high. The agency agreed with the report’s recommendations for increased oversight and audits.

CMS in a statement said it is “committed to ensuring that Medicare Advantage plans submit accurate information to CMS so that payments to plans are appropriate.”

Prior to these findings, Medicare estimated it had made $40 billion in overpayments to insurers from 2013 to 2016 due to diagnoses submitted by health plans not supported by medical records.

(Reporting by Chad Terhune; Editing by Bill Berkrot)

Trump to unveil order aiming to boost Medicare health program, woo seniors

By Jeff Mason

WASHINGTON (Reuters) – U.S. President Donald Trump will unveil an executive order on Thursday aimed at strengthening the Medicare health program for seniors, seeking to improve its fiscal position and offer more affordable plan options, administration officials said.

The order, which Trump will discuss during a visit to a retirement community in Florida known as the Villages, is the Republican president’s answer to some Democrats who are arguing for a broad and expensive expansion of Medicare to cover all Americans, proposals that Republicans reject.

It follows measures rolled out in recent months by the administration designed to curtail drug prices and correct other perceived problems with the U.S. healthcare system, though policy experts say those efforts are unlikely to slow the tide of rising drug prices in a meaningful way.

The Medicare program covers Americans who are 65 and older and includes traditional fee-for-service coverage in which the government pays healthcare providers directly and Medicare Advantage plans, in which private insurers manage patient benefits on its behalf.

Seniors are a key political constituency in America because a high percentage of them vote, and Florida is a political swing state that both parties woo in presidential elections.

The order is designed to show Trump’s commitment to keeping Medicare focused on seniors, administration officials said ahead of the announcement.

The order pushes for Medicare to use more medical telehealth services, which is care delivered by phone or digital means.

One administration official, who described the order to Reuters, said that would reduce costs by cutting down on the number of expensive emergency room visits by patients; lower costs would help strengthen the program’s finances.

The order directs the government to work to allow private insurers that operate Medicare Advantage plans to use new plan pricing methods, such as allowing beneficiaries to share in the savings when they choose lower-cost health services.

It also aims to bring payments for the traditional Medicare fee-for-service program in line with payments for Medicare Advantage.

Trump’s plans contrast with the Medicare for All program promoted by Bernie Sanders, a Democratic socialist who is running to become the Democratic Party’s nominee against Trump in the 2020 presidential election.

Sanders’ proposal, backed by left-leaning Democrats but opposed by moderates such as former Vice President Joe Biden, would create a single-payer system, effectively eliminating private insurance by providing government coverage to everyone, using the Medicare model.

“Medicare for All is Medicare for none,” said Seema Verma, the administrator of the U.S. Centers for Medicare and Medicaid Services, on a conference call with reporters, calling the proposal a “pipe dream” that would lead to higher taxes.

Sanders has argued that Americans would pay less for healthcare under his plan.

The White House is eager to show Trump making progress on healthcare, an issue Democrats successfully used to garner support and take control of the House of Representatives in the 2018 midterm elections. Trump campaigned in 2016 on a promise to repeal and replace the Affordable Care Act, his predecessor President Barack Obama’s signature healthcare law also known as “Obamacare,” but was not successful.

In July, the U.S. Department of Health and Human Services (HHS) said it would propose a rule for imports of cheaper drugs from Canada into the United States. A formal rule has not yet been unveiled.

The administration also issued an executive order in June demanding that hospitals and insurers make the prices they charge patients more transparent, as well as another in July encouraging novel treatments for kidney disease.

Trump considered other proposals that did not reach fruition.

A federal judge in July shot down an executive order that would have forced drugmakers to display their list prices in advertisements, and Trump scrapped another planned order that would have banned some of the rebate payments drugmakers make to payers.

The administration is also mulling a plan to tie some Medicare reimbursement rates for drugs to the price paid for those drugs by foreign governments, Reuters reported.

(Reporting by Jeff Mason; Additional reporting by Caroline Humer and Carl O’Donnell; Editing by David Gregorio)

Medicare hospital fund reserves likely to be exhausted in 2026: U.S. report

FILE PHOTO: U.S. Administrator of the Centers for Medicare and Medicaid Services (CMS) Seema Verma (C) is joined by Concerned Women for America CEO Penny Nance (L) at the White House in Washington, U.S., April 13, 2017. REUTERS/Jonathan Ernst/File Photo

(Reuters) – Medicare’s hospital insurance fund will be depleted in 2026, as previously forecast, and Social Security program costs are likely to exceed total income in 2020 for the first time since 1982, according to a government report released on Monday.

The report from the board of trustees for Social Security and Medicare also projected that Social Security funds could be depleted by 2035, leading to potential reductions in expected payouts to retirees and other beneficiaries.

U.S. healthcare costs are expected to be a hot topic during the 2020 presidential campaign, with uncertainty around possible cost-cutting solutions already weighing on healthcare stocks this year.

Senator Bernie Sanders, among a large field of contenders for the Democratic presidential nomination, has unveiled a “Medicare-for-All” plan that would eliminate private insurance and shift all Americans to a public healthcare plan.

However, Republicans have denounced the proposal as impractical and too expensive.

“At a time when some are calling for a complete government takeover of the American health care system, the Medicare Trustees have delivered a dose of reality in reminding us that the program’s main trust fund for hospital services can only pay full benefits for seven more years,” Seema Verma, administrator for the Centers for Medicare &amp; Medicaid Services (CMS), said.

The report said costs associated with the Medicare Supplementary Medical Insurance (SMI) trust fund, which covers drug costs in Part B and D in the program for seniors, are likely to grow steadily from 2.1 percent of gross domestic product in 2018 to about 3.7 percent of GDP in 2038, given the aging U.S. population and rising costs.

Cost projections for Part D drug spending, which covers prescription medicines obtained at the pharmacy, are lower than in last year’s report because of slower price growth and a trend of increasing manufacturer rebates, CMS said.

Part B primarily involves specialty drugs administered on an in-patient basis.

Trustees project that the SMI fund for Part B and Part D will remain adequately financed into the indefinite future because current law provides financing from general revenues and beneficiary premiums each year to meet the next year&rsquo;s expected costs.

The Trump administration in January proposed a rule that would overhaul the use of rebates in government-run healthcare plans, potentially ending a decades-long system under which drugmakers provide large discounts off the list price of their medicines to benefits managers and insurers rather than to consumers.

(Reporting by Tamara Mathias in Bengaluru; Editing by Bill Berkrot)

U.S. charges hundreds in major healthcare fraud, opioid crackdown

U.S. Attorney General Jeff Sessions addresses a news conference to announce a nation-wide health care fraud and opioid enforcement action, at the Justice Department in Washington, U.S. June 28, 2018. REUTERS/Jonathan Ernst

By Nate Raymond

(Reuters) – The U.S. Justice Department on Thursday announced charges against 601 people including doctors for taking part in healthcare frauds that resulted in over $2 billion in losses and contributed to the nation’s opioid epidemic in some cases.

The arrests came as part of what the department said was the largest healthcare fraud takedown in U.S. history and included 162 doctors and other suspects charged for their roles in prescribing and distributing addictive opioid painkillers.

“Some of our most trusted medical professionals look at their patients – vulnerable people suffering from addiction – and they see dollar signs,” U.S. Attorney General Jeff Sessions said.

The arrests came as part of an annual fraud takedown overseen by the Justice Department. The crackdown resulted in authorities bringing dozens of unrelated cases involving alleged frauds that cost government healthcare programs and insurers more than $2 billion.

Officials sought in the latest crackdown to emphasize their efforts to combat the nation’s opioid epidemic. According to the U.S. Centers for Disease Control and Prevention, the epidemic caused more than 42,000 deaths from opioid overdoses in the United States in 2016.

In a report released on Thursday, the U.S. Department of Health and Human Services’ Office of Inspector General said about 460,000 patients covered by Medicare received high amounts of opioids in 2017 and 71,000 were at risk of misuse or overdose.

Those figures were slightly down from 2016, but the report said the high level of opioid use remained a concern. The report said almost 300 prescribers had “questionable prescribing” that warranted further scrutiny.

Many of the criminal cases announced on Thursday involved charges against medical professionals who authorities said had contributed to the country’s opioid epidemic by participating in the unlawful distribution of prescription painkillers.

The cases included charges in Texas against a pharmacy chain owner and two other people accused of using fraudulent prescriptions to fill bulk orders for over 1 million hydrocodone and oxycodone pills that were sold to drug couriers.

“The perpetrators really are despicable and greedy people,” U.S. Health and Human Services Secretary Alex Azar said at a press conference.

The Justice Department also announced other cases unrelated to opioids, including schemes to bill the government healthcare programs Medicare, Medicaid and Tricare as well as private insurers for medically unnecessary prescription drugs and compounded medications.

(Reporting by Nate Raymond in Boston; Editing by Chizu Nomiyama and Tom Brown)

Companies need older workers: here is why

FILE PHOTO: Office workers take their lunch at a food court in Sydney, Australia May 4, 2018. REUTERS/Edgar Su/File Photo

By Mark Miller

CHICAGO (Reuters) – The demographic trend is no secret: the populations of the United States and other major industrial countries are getting older, and fast. That means workforces are aging too, but employers are doing surprisingly little to prepare to meet the challenges or adapt to employees’ needs.

In the United States, the 65-and-over population will nearly double over the next three decades to 88 million by 2050 from 48 million, according to the U.S. Census Bureau.

By 2024, one in four U.S. workers will be 55 or older, according to the U.S. Department of Labor, more than double the rate in 1994 when 55-plus workers accounted for just 12 percent of the workforce.

Many workers will face a financial need to keep working past traditional retirement ages, while others will want to work in order to stay engaged, notes Jonathan Rauch, a senior fellow at the Brookings Institute and author of “The Happiness Curve: Why Life Gets Better After 50.”

“People are getting to their sixties with another 15 years of productive life ahead, and this is turning out to be the most emotionally-rewarding part of life,” Rauch said. “They don’t want to just hang it up and just play golf. That model is wrong.”

A survey of human resource professionals by the Society for Human Resource Management in 2016 revealed a short-term mindset along with a lack of urgency among employers in assessing and planning for aging workforce.

Just 35 percent of U.S. companies have analyzed the near-term impact of the departure of older workers and just 17 percent have considered longer-term impactions over the next decade, according to the survey.

Most employers do not have a process for assessing the impact beyond one or two years, and the majority said they do not actively recruit older workers at all.

Alex Alonso, senior vice president of knowledge development at Society for Human Resource Management, thinks employers have sharpened their focus in this area since the survey was conducted.

“In most boardrooms, there is urgency around the topic these days, but the conversation is around how to sustain the enterprise, with a focus on how to manage a multi-generational workforce,” Alonso said.

Age discrimination, while difficult to prove, persists. Yet research over the past decade has gone a long way toward debunking stereotypes about older workers – that they are less productive and energetic, and less able to learn or solve problems.

But the bias continues.

Forty-one percent of companies around the world surveyed by Deloitte Consulting said they considered aging of their workforces a competitive disadvantage. The finding varied by country.

“It’s somewhat of a cultural issue,” said Josh Bersin, a principal at the consulting firm.

Employers such as Deloitte Consulting are starting to wake up to the issues as the labor market tightens, Bersin said. “I spend a lot of time with human resource departments around the world, and they are starting to realize that one of best talent pools they can recruit from are the people they already have.”

ALTERNATIVE CAREER ROUTES

Leading-edge employers are starting to think about creating alternative career routes for older workers that feature more flexible assignments and schedules, creating opportunities for them to mentor younger workers and offering phased retirement.

Deloitte, for example, now has a new set of professional career paths available for employees who are not on the track to become partners but have important specialized knowledge.

Among major manufacturers, automaker BMW is often cited as an innovator in valuing the skills and experience of older workers. The company has implemented changes to its production lines aimed at improving ergonomics of its work environment and promoting age-neutral language in the workplace.

The Columbia Aging Center at the Mailman School of Public Health in New York City has been honoring “age smart” employers for the past three years. Winning companies actively recruit and promote older workers, provide flexible work schedules and mentorship opportunities.

For example, one company honored this year, accounting firm PKF O’Connor Davies, actively hires older accountants when other firms compel them to retire. Of the firm’s 700 workers, more than 250 are over age 50. The firm offers flexible work options, including shorter work weeks.

“We’re definitely seeing growing concern about the drain of human capital among larger companies, and interest in new models for older workers that retain them longer,” said Linda Fried, dean of the Mailman School and head of the school’s Aging Center.

Fried acknowledges that some employers worry about the higher compensation and healthcare costs associated with older workers. She has proposed changing Medicare’s rules to accept older workers, allowing them to shift away from employer health plans. Other researchers have proposed incentivizing employers by creating a 40-year cap on the total years of work requiring payroll tax contributions to Social Security.

Changing attitudes also will be important.

“There is a lot more talk in business circles about the human capital value of older workers, but we’re still in early innings,” said Paul Irving, chairman of the Center for the Future of Aging at the Milken Institute. “It takes time for things to percolate.”

(Reporting by Mark Miller; Editing by Lauren Young and Matthew Lewis)

Soaring costs, loss of benefits top Americans’ healthcare worries: Reuters/Ipsos poll

An examination room is seen at an onsite health clinic at the Intel corporate campus in Hillsboro, Oregon, U.S., April 25, 2018. REUTERS/Caroline Humer

By Maria Caspani

(Reuters) – For over a year now, Americans have listed healthcare as the most important problem facing the country, according to Reuters/Ipsos polling.

When asked what concerns them about U.S. healthcare, this is what they had to say:

TOTAL COST OF HEALTH INSURANCE

Sixty-five percent of Americans said in the poll that they are “very concerned” about the overall cost of health insurance, including premiums, deductibles and copays.

This concern is consistent throughout the country: A majority of both millennials and baby boomers, whites and minorities, Democrats and Republicans were worried about healthcare costs.

PRESCRIPTION DRUGS

Nearly three in four Americans use prescription drugs, and 58 percent said they are “very concerned” about the cost of paying for them, according to the Reuters/Ipsos poll. These drugs are expected to see the fastest annual growth over the next decade, rising an average of 6.3 percent per year, according to the U.S. Centers for Medicare and Medicaid Services (CMS).

CHOOSING CARE

Sixty-six percent of U.S. adults who took part in the survey said they were concerned about their ability to see a doctor of their choice going forward.

MEDICARE AND MEDICAID

About one in three U.S. adults said they were “very concerned” about losing benefits from government-run programs Medicare and Medicaid.

Enrollment in Medicare is expected to increase as baby-boomers reach retirement age, according to CMS projections, which will contribute to growing healthcare spending.

The poll also showed that 58 percent of Americans think Congress should keep the Affordable Care Act either entirely as it is, or with some fixes, while 24 percent think lawmakers should repeal it once an alternative law is passed and 18 percent want the ACA to be repealed immediately.

The Reuters/Ipsos poll surveyed 3,982 people in English in the United States from May 22 to June 3 and it has a credibility interval of about 2 percentage points.

For more Reuters polling, visit http://polling.reuters.com/

(Reporting by Maria Caspani, Editing by Chris Kahn and Chizu Nomiyama)