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Here's some cheerful news: States and the federal government are doing little to stop a costly form of Medicaid fraud, according to a government report released last week. Medicaid, the federal-state health insurance program for poor Americans, now covers more than half its members through what's known as Medicaid managed care. States pay private companies a fixed rate to insure Medicaid patients. It has become more popular in recent years than the traditional "fee for service" arrangement, in which Medicaid programs reimburse doctors and hospitals directly for each service they provide. Despite the growth of managed care in recent decades, officials responsible for policing Medicaid "did not closely examine Medicaid managed-care payments, but instead primarily focused their program integrity efforts on [fee-for-service] claims," according to the Government Accountability Office, the investigative arm of Congress. The managed-care programs made up about 27 percent of federal spending on Medicaid, according to the GAO. The nonpartisan investigators interviewed authorities in California, Florida, Maryland, New Jersey, New York, Ohio, and Texas over the past 12 months. STORY: No Background Checks Needed for Home Health Workers in 10 States Funded jointly by the federal government and the states, Medicaid provided health insurance to about 72 million low-income Americans at a cost of $431 billion last year, according to the report. By the Medicaid agency's own reckoning, $14.4 billion of federal spending on Medicaid constituted "improper payments," which include both overpayments and underpayments. That's 5.8 percent of what the federal government spends on the program. The $14 billion figure doesn't tally what states lose to bad payments. The fraud risk for managed care is twofold. Doctors or other health-care providers could be bilking the managed-care companies, which pass on those fraudulent costs to the government.

Texas pays out $28 billion a year to some 4.8 million people, according to Kaiser. The state picks up one-fourth of the tab, and the feds pay the rest.  The FBI estimates that 10% of Medicaid claims are fraudulent, which comes out to $2.8 billion a year in Texas alone. On Monday, Austin company 21CT launches a new computer system called "Torch" to help the state bring scammers to justice. Torch will collate state data around the clock. The system will monitor frequency of claims, the size of claims and any funny patterns or anomalies. 21CT has grown to over 100 employees, most of them devoted to the crackdown. Company officials say what they are finding is eye opening. "You know it's there," said Kyle Flaherty, Vice President of Marketing for 21CT. "What's so surprising is how complex and entrepreneurial the fraudsters can be. This is a business for them and we need to disrupt the business they are creating." Torch will eyeball providers: businesses, medical supply companies, doctors, therapists, dentists, ambulance firms, hospitals and more. The system will make it easier to sort out.

I have really bad eyes. I like to get them checked often, but since I don't have health insurance, no doctor's going to really want to take a look at me," he said. He found out that he may qualify for Medicaid, which was long-drawn-out under Obamacare. So far, 9,123 have enrolled over Connecticut's ultimate goal is to sign up 275,000 people. Kevin Counihan, chief executive officer of Connecticut's health exchange, says he's not discouraged by the number of people signing up for private health insurance. "Buying health insurance is expensive and it's expensive and it's confusing and it's complicated. So no, I am not disappointed by it. However, we clearly have a strong goal to meet by March," he said. Counihan look forward to have 100,000 people enrolled by the end of March. He credits the state's computer system with the smooth even out. "Number one is, less is more. Do fewer things well than try to do more things inconsistently. Two is test the heck out of the system and make sure that before you go live, you are pretty darn confident that you know what is going to happen. And three is hire the best people that you can," he said. Counihan was implicated with Massachusetts' health insurance rollout in 2006. He says that taught him people don't buy insurance like they do a book or car. They usually consider the options an average of 18n times before making up their minds. He foresees a sprint of people signing up between Thanksgiving and Dec. 15, which in case is the deadline for coverage beginning on Jan. 1.

"Tuesday, November 12, statistics put out by Connecticut demonstrate that its website is the only one to sign up more folks for private insurance than for Medicaid. Angel Medina, 21, went to talk to an Affordable Health Care act navigator in Hartford. Medina was dropped from his mother's health insurance two years ago. "I have really bad eyes. I like to get them checked often, but since I don't have health insurance, no doctor's going to really want to take a look at me," he said. He found out that he may qualify for Medicaid, which was long-drawn-out under Obamacare. So far, 9,123 have enrolled over Connecticut's ultimate goal is to sign up 275,000 people. Kevin Counihan, chief executive officer of Connecticut's health exchange, says he's not discouraged by the number of people signing up for private health insurance. "Buying health insurance is expensive and it's expensive and it's confusing and it's complicated. So no, I am not disappointed by it. However, we clearly have a strong goal to meet by March," he said. Counihan look forward to have 100,000 people enrolled by the end of March. He credits the state's computer system with the smooth even out. "Number one is, less is more. Do fewer things well than try to do more things inconsistently. Two is test the heck out of the system and make sure that before you go live, you are pretty darn confident that you know what is going to happen. And three is hire the best people that you can," he said. Counihan was implicated with Massachusetts' health insurance rollout in 2006. He says that taught him people don't buy insurance like they do a book or car. They usually consider the options an average of 18n times before making up their minds. He foresees a sprint of people signing up between Thanksgiving and Dec. 15, which in case is the deadline for coverage beginning on Jan. 1."

A pair of editorials last week took up the issue of Medicare and Medicaid fraud, waste and abuse, signifying these problems are becoming a greater focus of public attention and debate "Area ambulance companies are facing deserved scrutiny for their disproportionate share of the nation's outsize[d] healthcare costs," The Inquirer wrote. Ground ambulance providers around Philadelphia collected 64 percent more Medicare dollars than the national average in 2012, with 33 area companies raking in 10 times the norm, the article noted. "No wonder Medicare has stopped taking new company enrollments while it sorts out the fraud," the article stated. The Inquirer referenced charges against eight local ambulance providers since 2011, including one's five-year prison sentence for executing a $3.6 million scam involving kickbacks for unnecessary transport. "Medicare is still not as open [as] it should be," the editorial said. "It has spurned numerous attempts by The Inquirer to get additional information on the ambulance companies that are costing the government the most." The paper wants to know if aberrant providers still collect federal money and if Medicare demanded overpayment refunds. Meanwhile, a Farmington Daily Times editorial highlighted the case of Agave Health, Inc., an Arizona mental health services company that in six months received more than $172,000 from Medicaid. Half this money was disbursed before the completion of a state audit led to a funding freeze for 15 nonprofit healthcare providers. "The question is whether those payments suggest state officials prejudged the conclusion of the audit before it was completed," the editorial stated. That audit exposed $36 million in Medicaid overpayments, the Times reported, which led New Mexico to halt Medicaid funding to in-state providers and shift business to Arizona companies like Agave. But New Mexico paid Agave more than it paid in-state providers.

MEDICAL science is hazy about many things, but doctors agree that if a patient is losing pints of blood all over the carpet, it is a good idea to stanch his wounds. The same is true of a health-care system. If crooks are bleeding it of vast quantities of cash, it is time to tighten the safeguards. In America the scale of medical embezzlement is extraordinary. According to Donald Berwick, the ex-boss of Medicare and Medicaid (the public health schemes for the old and poor), America lost between $82 billion and $272 billion in 2011 to medical fraud and abuse (see article). The higher figure is 10% of medical spending and a whopping 1.7% of GDP-as if robbers had made off with the entire output of Tennessee or nearly twice the budget of Britain's National Health Service (NHS). Crooks love American health care for two reasons. First, as Willie Sutton said of banks, it's where the money is-no other country spends nearly as much on pills and procedures. Second, unlike a bank, it is barely guarded. Some scams are simple. Patients claim benefits to which they are not entitled; suppliers charge Medicaid for non-existent services. One doctor was recently accused of fraudulently billing for 1,000 powered wheelchairs, for example. Fancier schemes involve syndicates of health workers and patients. Scammers scour nursing homes for old people willing, for a few hundred dollars, to let pharmacists supply their pills but bill Medicare for much costlier ones. Criminal gangs are switching from cocaine to prescription drugs-the rewards are as juicy, but with less risk of being shot or arrested. One clinic in New York allegedly wrote bogus prescriptions for more than 5m painkillers, which were then sold on the street for $30-90 each. Identity thieves have realised that medical records are more valuable than credit-card numbers.

Tips for navigating Obamacare http://www.westhillinsuranceconsulting.com/blog/westhill-consulting-tips-for-navigating-obamacare/ Think hard before your drop insurance entirely Tambe said that might not make good business sense despite some companies might be tempted to abolish insurance benefits completely and let employees go to marketplaces to get coverage. The problem is insurance purchased on the marketplace will be more expensive for individuals. Then the company will risk talent leaving the company for a competitor who offers them the less expensive option if the company isn't willing to compensate by raising their salary. "It may work to keep costs down but you'll have a hard time keeping talented folks," he said. Other federal programs could help you For households making under 400 percent of the Federal Poverty Level, the ACA grants subsidies available on the public marketplace under certain circumstances. Additionally there are current efforts for Ohio to spread out the Medicaid program to households making less than 138 percent of the poverty level. This in turn if acted out would make more people eligible for those programs. Not all individuals will qualify for subsidy even though most Americans will be eligible to obtain coverage through the exchange. Employer-sponsored coverage may affect an employee's ability to meet the criteria for the subsidy. If there are many employees qualify for federal assistance, it will be reasonable to let them use those plans, particularly since employees being offered insurance by an employer aren't allowed onto the marketplace if their employer is offering insurance deemed affordable, or 9.5 percent of their wage rate based on 130 hours per month for single coverage. "A lot of folks qualify for these things, and there's no penalty to employers," Tambe said. Know the paperwor

When the subject of health insurance is discussed someone raises the argument that because Medicare or Medicaid are government programs, they are subject to fraud. This is usually an objection from politicians who support Free Enterprise and fear Big Government. Let's be honest with ourselves, any human event that involves something of value attracts fraudsters. A bank robber, a hacker, a big company submitting false claims; all fall into the category of fraud. Any googling of Medicare fraud brings up some infuriating examples. For example, health care industry giant HCA (which the New York Times notes was bought by Bain Capital in 2006) eventually settled a Medicare fraud scandal (overcharging) for more than $1.7 billion. Or, last May the feds arrested 107 health care providers, including doctors and nurses, in several cities and charged them with cheating Medicare out of $452 million. In 2010, 94 people were charged with submitting $251 million in phony claims. Fraud isn't the product of scheming low-income beneficiaries - Mitt Romney's 47 percent - it is most often committed by big companies and rich doctors, not a patient seeking a second colonoscopy. We should admit that fraud is endemic to the insurance business, whether public or private. The Coalition Against Insurance Fraud estimates that in 2006 a total of about $80 billion was lost in the United States due to insurance fraud. According to estimates by the Insurance Information Institute, insurance fraud accounts for about 10 percent of the property/casualty insurance industry's incurred losses and loss adjustment expenses. So, how to tackle any fraud. Putting more police on the streets is an acceptable way of reducing crime. Private industry is free to hire as many investigators and accountants as it takes to catch fraudsters.

Dear Savvy Senior, I just turned 65 and received my Medicare card. I see that the ID number on my card is the same as my Social Security number, and on the back of the card it tells me I need to carry it with me at all times. What can I do to protect myself from identify theft if my purse and Medicare card get stolen? Answer: Many people new to Medicare are surprised to learn that the ID number on their Medicare card is identical to their Social Security number (SSN). After all, we're constantly warned not to carry our SSN around with us, because if it gets lost or stolen, the result could be identity theft. But the Medicare ID is more than an identifier. It's proof of insurance. Beneficiaries need to show their Medicare card at the doctor's office and the hospital in order to have Medicare pay for treatment. Over the years, many consumer advocates, have called for a new form of Medicare identification. The Centers for Medicare & Medicaid Services, which administers Medicare, also acknowledges the problem, but so far nothing has been done. One of the main reasons is because it would cost an estimated $255 to $317 million to fix it. And that's just the direct cost to the federal government. It doesn't include the expense for physicians and other health care providers to adjust their systems, or the cost to the states. Other government health systems like the Department of Veterans Affairs and Department of Defense have already begun using ID numbers that are different from SSNs, but no one knows when Medicare will follow suit. In the meantime, here are some tips offered by various consumer advocate groups that can help keep your Medicare card safe and out of the hands of fraudsters. * For starters, AARP suggests that you simply don't carry your Medicare card at all, because it's not necessary. Most health care providers already have their patients in their electronic systems and know how to bill you.

According to the Centers for Medicare and Medicaid Services, healthcare costs are expected to rise by 5.8% each year until 2022, which is going to make for a pretty serious hike in your expenses. Instead of getting frustrated and giving in, though, put your thinking cap on. If you're willing to roll your sleeves up and do a little research, you can find plenty of ways to reduce your medical costs. Here are six of them. 1. Use Urgent Care Facilities Instead of the Emergency Room It's a pretty decent bet that there's an urgent care facility near where you live that you can use in lieu of the emergency room. It won't cost you as much, and many such facilities offer extended hours. Don't wait for the next time an emergency occurs - do an Internet search now to find suitable locations and note their hours of operation. 2. Improve Your Health One of the simplest ways to decrease your medical costs is to improve your health. If you're overweight, join a gym or create a home workout program and adjust your diet to include more fresh fruits and vegetables. Still smoking cigarettes? Buy a patch or join a support group and quit. Got friends who encourage you to party it up on the weekends? Find yourself some new ones or convince them to participate in healthier activities. Concrete steps like these can get you more fit and less likely to need medical attention. 3. Get Generic Prescription Medication Whenever your doctor prescribes any medication, be sure to ask for a generic option. You can save as much as 85%, according to the Food and Drug Administration, which also points out that you don't sacrifice anything in quality by avoiding brand name meds. 4. Pay Your Bill Upfront If you have the means to do so, offer to pay your medical bill upfront for a negotiated discount. This is a shrewd and under-used method to reduce your medical costs. See the billing department at the hospital or your doctor's office for details. 5. Use Your Smartphone A variety of mo

When investigators suspected that Houston's Riverside General Hospital had filed Medicare claims for patients who weren't treated, they moved to block all payments to the facility. Then politics intervened. Rep. Sheila Jackson Lee, a Texas Democrat, contacted the federal official who oversees Medicare, Marilyn Tavenner, asking her to back down, according to documents reviewed by The Wall Street Journal. In a June 2012 letter to Ms. Tavenner, Rep. Jackson Lee said blocking payments had put the hospital at financial risk and "jeopardized" patients needing Medicare. Weeks later, Ms. Tavenner, administrator of the Centers for Medicare and Medicaid Services, instructed deputies to restore most payments to the hospital even as the agency was cooperating in a criminal investigation of the facility, according to former investigators and documents. "These changes are at the direction of the Administrator and have the highest priority," a Medicare official wrote to investigators. About two months after that order, Riverside's top executive was indicted in a $158 million fraud scheme. The hospital was barred from Medicare this May, and the CEO was convicted in October. What happened at Riverside General Hospital shows how political pressure from medical providers and elected officials can collide with efforts to rein in waste and abuse in the nearly $600 billion, taxpayer-funded Medicare system. More than a dozen former investigators and CMS officials said in interviews that they faced questions from members of Congress about policy changes or punitive action affecting providers or individual doctors.

I. The Anti-Kickback Statute One purpose of the anti-kickback statute is to protect patients from inappropriate medical referrals or recommendations by health care professionals who may be unduly influenced by financial incentives. Section 1128B(b) of the Social Security Act (the Act) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce, or in return for, referrals of items or services reimbursable by a Federal health care program. When remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute a scribes criminal liability to parties on both sides of an impermissible "kickback" transaction. Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to 5 years, or both. Conviction will also lead to exclusion from Federal health care programs, including Medicare and Medicaid. OIG may also initiate administrative proceedings to exclude persons from the Federal health care programs or to impose civil money penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act. II. Remuneration From Laboratories to Referring Physicians Arrangements between referring physicians and laboratories historically have been subject to abuse and were the topic of one of the OIG's earliest Special Fraud Alerts. 1 In that Special Fraud Alert, we stated that, "[w]henever a laboratory offers or gives to a source of referrals anything of value not paid for at fair market value, the inference may be made that the thing of value is offered to induce the referral of business.

Dear Savvy Senior, I just turned 65 and received my Medicare card. I see that the ID number on my card is the same as my Social Security number, and on the back of the card, it tells me I need to carry it with me at all times. What can I do to protect myself from identify theft if my purse and Medicare card get stolen? Conflicted beneficiary Dear Conflicted, Many people new to Medicare are surprised to learn that the ID number on their Medicare card is identical to their Social Security number (SSN). After all, we're constantly warned not to carry our SSN around with us, because if it gets lost or stolen, the result could be identity theft. But the Medicare ID is more than an identifier. It's proof of insurance. Beneficiaries need to show their Medicare card at the doctor's office and the hospital in order to have Medicare pay for treatment. Over the years, many consumer advocates have called for a new form of Medicare identification. The Centers for Medicare & Medicaid Services, which administers Medicare, also acknowledges the problem, but so far nothing has been done. One of the main reasons is because it would cost an estimated $255 million to $317 million to fix it. And that's just the direct cost to the federal government. It doesn't include the expense for physicians and other health care providers to adjust their systems or the cost to the states. Other government health systems like the Department of Veterans Affairs and Department of Defense have already begun using ID numbers that are different from SSNs, but no one knows when Medicare will follow suit. In the meantime, here are some tips offered by various consumer advocate groups that can help keep your Medicare card safe and out of the hands of fraudsters.

Millions of Americans gained health insurance coverage under the Patient Protection and Affordable Care Act this year, but the influx apparently has not yet translated into patients packing doctors' offices. That may reflect a lack of understanding about how and where to seek care-and a lack of outreach by their new plans and providers. "If coverage expansion is allowing patients to establish new relationships with physicians, we would expect to see physicians devote a greater share of their calendars and work effort to caring for new patients," wrote the authors of a report released this week by the Robert Wood Johnson Foundation and Athenahealth, a company that sells cloud-based health information and practice management technology. But that is not what they found. Though it may seem counterintuitive, the organizations discovered that during the first five months of 2014, all specialties-with the exception of pediatrics-experienced lower rates of new-patient visits than they had in the year-ago period. This was based on data taken from more than 14,000 providers across specialties. For example, the proportion of visits from new patients to primary-care physicians in the sample from January to May 2014 was 18.8% compared with 19.3% during that same five-month period in 2013. The study did not analyze what caused this decline, but the authors suggest that one reason is that the newly insured are continuing to go to emergency departments instead of physician offices. That explanation seems consistent with studies that showed increased emergency department use after pre-ACA expansions of health insurance in Massachusetts and Medicaid in Oregon.