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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.

Westhill Consulting Insurance - How to Avoid Health Care Fraud Mail-order medications Patients who buy drugs through mail-order companies could be rolling the dice with their health says Dr. Deborah C. Peel, a physician and founder of the nonprofit Patient Privacy Rights. There's a high probability in many cases that these drugs are counterfeit Peel added. "And you don't ever know because the fraudulent tablets look just like the real ones," says Peel. She says ordering from companies that specialize in mail-order sales that are not affiliated with a legitimate insurance company, especially from foreign countries, can be very risky. Not only could the quality be questionable, it could also be illegal. "But people are desperate because we're being so grossly overcharged for medication," she says. Peel says you can lessen costs by buying generic. You can spot it by: the best thing to do is to keep away from buying drugs from foreign or obscure pharmacies. And if you decide to go with the mail-order route, just stay with U.S.-based companies because if it's a U.S. company, you can report the health care fraud to the Food and Drug Administration while if it's a foreign company, there's little that can or will be done. False product claims According to the Federal Trade Commission, millions fall victim each year to false miracle cures. Especially vulnerable are victims of debilitating and potentially deadly illnesses such as cancer, multiple sclerosis, HIV and AIDS. The FTC website says scammers take advantage of people with a grim diagnosis such as cancer and "promote unproven - and potentially dangerous - substances like black salve, essiac tea, or laetrile with claims that the products are both 'natural' and effective." But, say physicians and other experts, simply because something is advertised as "natural" doesn't mean it works. And while a patient is experimenting with bogus treatments, he or she can squander the opportu

A 27-year-old in Jackson pays $336 a month for the second-cheapest silver health plan on Mississippi's s federally run insurance marketplace. That is more than twice as much as the $154 a 27-year-old in Nashville would pay for the same type of policy, and the $138 for a similar person in Tucson. Across all 34 insurance marketplaces run by the federal government, the average is $287, about 25 percent cheaper. The reason for the higher prices in some markets? Paltry competition, say Leemore Dafny and Christopher Ody from Northwestern University, and Jonathan Gruber of the Massachusetts Institute of Technology. Jackson has only two insurers on the marketplace: Humana and Centene. By contrast, four insurance companies slug it out on Nashville's exchange. In Tucson, there are eight. Jackson's over-the-top premiums underscore one of the least-heralded shortcomings of the rollout of the Affordable Care Act: the scarcity of insurers on health plan exchanges, which is driving up the price of policies across the country. The research by Ms. Dafny, Mr. Gruber and Mr. Ody, to be published by the National Bureau of Economic Research next week, concludes that premiums on the exchanges are 11 percent higher than they would be if all the health insurance companies that sell policies in each state had participated in the new markets for health plans. More competition not only would lower premiums, but would also save the federal government money. It would spend $1.7 billion less in subsidies to low- and middle-income Americans buying policies on the health care insurance exchanges. "Half of the population in the states with health exchanges facilitated by the federal government is served by three insurers or fewer," Ms. Dafny said. "To have competition on the exchanges you need competitors." The findings are somewhat perplexing, though. By law, 80 to 85 percent of premiums must be devoted to medical spending. Insurers don't have particularly large profit margin

Not long after she signed up for health insurance under the Affordable Care Act, Judy Shoemaker received a phone call that puzzled her. The caller said she was welcoming new members to the insurance network and then asked Ms. Shoemaker to take a survey about health care issues, so information could be provided to her physician. Ms. Shoemaker declined, saying she didn't understand why her insurer would be seeking medical information to give to her doctor. "I thought it was strange," said Ms. Shoemaker, a consultant to nonprofits in Indiana. "I can talk to my doctor myself." James Tuck, who runs a dog care business in Chicago, got a similar call after signing up for insurance through the Affordable Care Act in March. The caller said he was contacting Mr. Tuck on behalf of his new insurer, Blue Cross Blue Shield of Illinois, to go over his benefits and ask him some questions. Mr. Tuck hadn't yet received his insurance card and was hesitant to answer questions, especially after he consulted a private health advocate, who had helped him evaluate insurance options. She advised him not to answer the queries. "She said their goal is to find a reason to get you booted off your insurance." Insurers say they are doing nothing of the sort. Lauren Perlstein, a spokeswoman for the Health Care Service Corporation, parent of Blue Cross Blue Shield of Illinois and plans in four other states, said in an email that the company contacted new policy holders to help "new members get the proper coverage and medical assistance they need, by helping guide them through the health care system." The company's "experts" contact new members to explain benefits and answer any questions, she said, as well as to "identify members who can benefit from our personalized medical management program so they can best manage their health."

Hep C Cure Costs Pose Challenge for Medicare By Richard Knox NPR   Walter Bianco has had hepatitis C for 40 years, and his time is running out. "The liver is at the stage next to becoming cirrhotic," the 65-year-old Arizona contractor says. Cirrhosis is severe scarring, whether from alcoholism or a chronic viral infection. It's a fateful step closer to liver failure or liver cancer. If he develops one of these complications, the only possible solution would be a hard-to-get liver transplant. "The alternative," Bianco says, "is death." Previous drug treatments didn't clear the virus from Bianco's system. But it's almost certain that potent new drugs for hep C could cure him. However, the private insurer that handles his medication coverage for the federal Medicare program has twice refused to pay for the drugs his doctor has prescribed. Doctors are seeing more and more patients approaching the end-stage of hep C infection. "There isn't day that goes by when I don't have a story very similar to Mr. Bianco's," says Dr. Hugo Vargas of Mayo Clinic in Scottsdale, Ariz., his liver specialist. Researchers estimate that 3 to 5 million Americans carry the insidious hep C virus. The biggest concentration is among those born between 1945 and 1965.

As we grow older, our responsibilities add up. Having a health insurance should be one of the priorities that we should think of. By the time you are old enough to fend for yourself, you are then required to get an insurance. However, many young adults are still confused on its importance. 1. It may be Illegal When you are living in the United States, Affordable Care Act (ACA) compels you to purchase insurance. Going without insurance for three months would force you to pay a penalty of $325 or 2% of your monthly income, whichever is higher. In developing countries, uninsured individuals have the option to purchase from private companies but laws are already drafted for completion. In cities like Jakarta, Indonesia and Bangkok, Thailand, more than half of their unemployed population goes uninsured. 2. If you are a full-time employee, your employer should provide you with insurance Most companies require employees work for set period before benefits can be provided. It usually takes 3-6 months in a probationary period before regularization, by which insurance is given. It is in any law in any states and government to mandate to every employer to provide employee benefits. 3. Your parents may still be able to cover you Individuals under the age of 26 can still be listed under their parents' coverage. They can still cover even a modest premium cost. 4. You can do it alone If you are not insured under your parents' plan or purchasing insurance under your employer is not an option, you have the choice to purchase your own insurance from trusted private companies. If you are buying online, just make sure you

WASHINGTON - The Obama administration has been struggling to clear up data discrepancies that could potentially jeopardize coverage for millions under the health overhaul, the government's health care fraud watchdog reported Tuesday. The Health and Human Services inspector general said the administration was not able to resolve 2.6 million so-called "inconsistencies" out of a total of 2.9 million such problems in the federal insurance exchange from October through December 2013. Of the roughly 330,000 cases that could be straightened out, the administration had only actually resolved about 10,000 during the period of the inspector general's audit. That worked out to less than 1 percent of the total. Several states running their own insurance markets also were having problems clearing up data discrepancies. Most of the issues dealt with citizenship and income information supplied by consumers that conflicted with what the federal government has on record, the report said. It marked the first independent look at a festering behind-the-scenes issue that could turn into another health law headache for the White House. President Barack Obama celebrated 8 million sign-ups as proof that technical problems which initially kept many consumers from enrolling had finally been overcome. It now turns out that some of those problems continued out of sight. The inspector general said the efforts of the administration and states to clear up the discrepancies were complicated by lingering computer issues.

How to spot and stop health insurance scams Medical and health insurance scams are rampant. Both government and private initiatives have renewed their focus on preventing health insurance fraud and abuse. Michael Williams, director of communications and membership of the National Health Care Anti-Fraud Association, says new and better technology, improved awareness, and more widely available information combine to combat fraud. Williams adds that while the majority of physicians run honest practices, consumers must also step up to the plate to prevent fraud. "Pay attention, do your research, read your EOBs (explanations of benefits) and beware of free offers," he says. Read on to discover some of the most common health insurance scams making the rounds and ways experts like Williams say you can guard against becoming another victim. Fake insurance policies Like counterfeit money, bogus health insurance is not only circulating, but it's becoming increasingly common. James Quiggle, communications director of the Coalition Against Insurance Fraud, says fake policies are particularly virulent. "These crooks come out of the woodwork and promise affordable premiums, no medical exams and guaranteed acceptance," Quiggle says, adding that the criminals who offer worthless policies often operate through sophisticated networks with strong marketing arms and money-laundering components. Many times they can be tied to organized crime. Often, these con artists target small businesses, unions and associations. It's only when a policyholder needs the insurance that the game's up.

Thom Tillis is stuck at the state capitol trying to resolve a budget quarrel as speaker of the North Carolina House. It's a spot that helps Hagan emphasize Tillis' role leading a Republican-controlled state government that Democrats contend has gone overboard with conservative zeal by restricting access to abortion and the voting booth while cutting corporate taxes and slashing spending on schools. (Hagan, the daughter of Joe P. Ruthven, grew up in Lakeland.) If Tillis is worried by Hagan's portrayal, he doesn't show it. Drinking coffee last week from a hand-grenade-shaped mug in his no-frills legislative office, he's got his own message in his campaign to take Hagan's Senate seat. "Obamacare," he said, "continues to be a big problem." Similar themes are playing out in other crucial Senate races, as voters have four months to decide which party will control the chamber in the final two years of Barack Obama's presidency. For Republicans, it's all about tying Democrats to Obama - especially to a health care law that remains unpopular with many Americans. And for Democrats, the election is about just about anything else, especially if they can steer attention away from Washington and federal matters. It's a political strategy that sometimes gives the campaigns an inside-out feel, with veteran senators running as if they were first-timers without a Washington resume to defend or tout.