New York Regulators Slash Health Insurance Rates For 2015

The average health insurance rate increase next year will be about 6 percent in New York State.

State regulators today set the rates for 2015 after reviewing proposals from insurers, which requested an average increase of about 13 percent. Westhill Healthcare Consulting

While some reduction was expected, some insurers told the Albany Business Review severe 2015 rate cuts by state regulators would harm the companies.

The state Department of Financial Services sets the rates.

“We closely scrutinized the proposed rate increases insurers requested and reduced them significantly where appropriate,” Benjamin Lawsky, superintendent of the department, said when announcing the reductions. Westhill Healthcare Consulting Review

On one hand, CEOs of insurers said the rate increases must properly reflect rising medical costs. They also cited increased taxes and fees tied to the Affordable Care Act, or ACA, as a main factor in proposing the 13 percent average rate hikes. They warned recent losses and job cuts at insurers would only get worse if rates insufficiently increased in 2015.

On the other hand, some business owners say they can’t afford the rate hikes. Prior to state regulators setting the average rate increase at 6 percent, business owners told the Albany Business Review that the 13 percent average increases for 2015 would threaten health benefit packages they offer workers.

In response to state regulator’s decision to reduce the rates, Paul Macielak, president and CEO of the New York Health Plan Association, an industry trade and lobbying group representing health insurers, described the figures as irresponsible. He warned some insurers may rethink offering some coverage plans and products instead of adhering to the state adjusted rates.

“The bottom line is inadequate rates will result in reducing product choice or otherwise de-stabilizing the market, which is ultimately harmful to the health care system as a whole and the consumers who rely on it,” Macielak wrote in an email.

On the individual market, the average increase will be about 5.7 percent, down from the 12.5 percent requested by insurers.

For the small group market, the average increase will be 6.7 percent, down from 13.9 percent requested by insurers.

Here are details from the state Department of Financial Services about rates for each insurer.

The Albany Business Review also previously talked with health care leaders who explained why state regulators would reduce the proposed rates.

If Your Kids Get Free Health Care, You’re More Likely to Start a Company

Starting a business is risky enough in the best of circumstances. Most new ventures fail, and the prospect of forgoing a salary is enough to keep many would-be entrepreneurs from taking the plunge.

But think about how much harder it would be if your child had a health condition, and you couldn’t get her insurance if you struck out on your own.

That’s less of a problem in the U.S. than it was a few years ago, thanks to Obamacare, but until recently it was a very real conundrum. So does the extension of publicly provisioned health insurance prompt more people to start companies? That’s the question asked by a paper released earlier this year by Gareth Olds of Harvard Business School.

Olds analyzed Census data from before and after the passage of the Children’s Health Insurance Program in the U.S. in 1997 to assess its impact on entrepreneurship. CHIP, or SCHIP as it was previously known, provides publicly funded health insurance to children whose families don’t qualify for Medicare, but whose incomes still fall below a cutoff (typically around 200% of the federal poverty line).

His results suggest that the policy did significantly increase business creation by those families affected. The self-employment rate for CHIP recipients increased from just under 15% of those eligible to over 18%. That amounts to an a 23% increase. The rate of ownership of incorporated businesses — a better proxy for sustainable, growth entrepreneurship — increased even more dramatically, from 4.3% to 5.8%, an increase of 31%.

What about all the other factors that might skew this sort of analysis? Olds used several quasi-experimental statistical methods in his research to control for such variables. The basic intuition behind his methods is that a family just above the CHIP cutoff isn’t all that different from a family just below it. Whether you make 199% of the poverty line or 201% doesn’t matter for much, except whether or not you’ll be able to enroll in the program. With that in mind, his methods zero in on this sub-group, in order to confirm that the policy actually caused the increase in firm creation.

The mechanism by which Olds believes CHIP boosts entrepreneurship is relatively straightforward: it reduces the risk of “consumption shocks,” i.e. the possibility of having to pay out a large chunk of cash unexpectedly for a child’s illness. Lower the risk and more people start companies.

Though it may seem counterintuitive given the political rhetoric around social insurance and economic growth, Olds’ is not the only research to suggest that welfare programs can promote entrepreneurship. Previous research has found that American self-employment rates jump at 65. Why is 65 a better age to start a company than 64? Because you qualify for health insurance through Medicare.

All of this serves as a reminder that bigger government needn’t discourage entrepreneurship and risk-taking. The relationship between the two ultimately depends on what government chooses to spend money on.

The final takeaway from Olds’ work is just how many business owners do depend on public programs like CHIP. “12% of households with incorporated businesses report enrollment in a public program,” he writes, not even counting Social Security, Medicare, or veterans benefits. And “disproportionately more entrepreneurs are receiving public healthcare benefits than would be expected based on their income alone.”

Overall, though, entrepreneurs still hail from disproportionately well-off families. The lesson from Olds’ paper is that starting a business doesn’t have to be a risk only wealthy people can afford to take — and the government can help.

How to Spot and Prevent Medical Identity Theft

Foxbusiness.com | westhill consulting insurance - While credit card breaches at retailers are grabbing headlines, identity thieves are quietly homing in on an even more lucrative area: health insurance and medical records.

More than 1.8 million people in the U.S. were victims of medical identity theft in 2013, according to a survey by the Ponemon Institute released in September. That’s a 19 percent increase over the previous year. “Medical identity theft is the fastest growing component of ID theft,” says Drew Smith, founder and CEO of InfoArmor, a provider of business-to-business identity theft solutions.

 

The latest case involves the alleged theft by Chinese hackers of 4.5 million medical records from Community Health Systems, a company that runs 206 hospitals in 29 states. Thieves stole records including names, addresses, birth dates, telephone numbers and Social Security numbers. Like any type of identity theft, medical ID theft can damage your credit and cost you hours of hassles trying to clear it up. But it could also endanger your life if incorrect information appears on your medical records.  Why the bull’s-eye? Health information is easier to hack than credit. In April, the FBI issued a private industry notification warning to health care providers that their data networks are not as robust as those in the financial and retail sectors, and “the possibility of increased cyber intrusions is likely.” 

Safeguards are in the works, but the move to electronic records and the health exchanges set up under the Affordable Care Act, otherwise known as Obamacare, have opened new opportunities for fraud, both online and off. Experts say Americans can expect to see medical fraud heat up again in the months before open enrollment for 2015 government-subsidized insurance begins in November 2014. 

Your medical ID: black market gold

Why would hackers bother with health insurance when they could get a direct line to your pocketbook via credit cards or financial accounts? “It’s very lucrative,” says Ann Patterson, senior vice president and program director at the Medical Identity Fraud Alliance. “Stolen protected health information can be monetized for a much greater value than traditional financial account information.” 

A complete medical identity — including name, address, phone number, Social Security number, medical insurance information and access to medical records — is worth about $50 on the black market, says Michael Bruemmer, vice president of Experian’s Data Breach Resolution group. “Without medical or insurance information, that drops to about $10 for someone’s stolen information.” Bruemmer’s group helped resolve 1,000 health care client breaches last year, including the largest breach of HIPAA, the Health Insurance Portability and Accountability Act. 

Medical identity theft usually happens on a large scale, with hundreds or even thousands of identities stolen at one time. Once hackers have a medical ID, they can use it to procure prescription drugs or expensive medical equipment or simply to commit financial fraud — often for months or years before anyone notices. Why? Partly because people don’t pay much attention to their medical or insurance records. While most of us wouldn’t let a bank or credit card statement go unread, we tend to ignore the explanation of benefits (EOB) issued by our health insurance after we have a doctor’s appointment or medical procedure. 

'Friendly' fraud common

More than half of all medical identity theft is what’s known as “friendly fraud” or “a victimless crime,” according to the Ponemon Institute study. A typical example: an uninsured sibling or friend borrows your insurance card for a procedure, with or without your permission. 

In 2013, the Medical Identity Fraud Alliance interviewed 800 victims of medical fraud. When asked what they would do differently, half said nothing. “Especially with the Robin Hood or ‘victimless’ crime, most people don’t think there are consequences,” says Patterson. “They say it’s no big deal.”  Yet there is no such thing as victimless medical identity theft. “If your sister has allergies that you don’t have or a different blood type, her allergies and blood type are now comingled in your records,” Patterson says. If you’re unconscious and need an emergency transfusion or injection, that misinformation can kill you. 

That kind of consequence comes, in equal measure, from both friendly and malicious medical identity theft, yet we continue to be lax about sharing our health information. “As a society, we just look at health in a very different way than we look at our finances,” Patterson says. 

Detecting medical fraud before it hurts you

Sometimes it takes a questionable medical bill to alert someone of a compromised medical identity, but even that doesn’t always do the trick. Many people simply ignore such bills from their insurance companies. By the time a red flag goes up, your insurance may have been used to procure prescription drugs, black-market medical equipment and emergency room visits. 

The consequences can be expensive. The Ponemon Institute found that 36 percent of medical ID theft victims pay to resolve the issue, and their out-of-pocket costs average nearly $19,000. Even if you don’t end up paying out of pocket, such usage can wreak havoc on both medical and credit records, and clearing that up is a time-consuming headache. That’s because medical records are scattered. Unlike personal financial information, which is consolidated and protected by credit bureaus, bits of your medical records end up in every doctor’s office and hospital you check into, every pharmacy that fills a prescription and every facility that processes payments for those transactions. 

Bruemmer expects that will change soon, with more progressive states raising the bar. “California, in particular, has the most stringent standard for what constitutes a medical or health care breach,” he says. If an individual’s username and password is compromised on a health care portal there, the provider is required to notify him or her within five days, Bruemmer says. “I actually think that’s the way the industry is going and there will be more regulations across more states,” Bruemmer says. 

Compiling a composite identity for the big scam

One small breach of information here and there may not seem like much, but each one could be adding up to something serious. “Five years ago, most hackers were looking for Social Security numbers, credit card numbers. They were going for the quick, easy fraud,” says Smith. “Today, they’re looking to steal someone’s health credentials, insurance information, credit card account passwords, so they can continue to monetize victims’ identities over a longer period of time.” 

"Thieves are getting smart," Bruemmer agrees. "One organization may take a username and password, another is your credit information, and another is your Social Security number. The last one may actually get your medical records. What they’re doing is amassing, in three or four incidents over a period of time, the full identity stream." Bruemmer says, for example, that thieves often use hacked email accounts to gain personal information. "People say, ‘Oh, it’s just the username and password for my email account, I’ll just change that.’ You’d be surprised how many people forget and let it go. Then, all of a sudden, something really bad happens." 

As with any organized crime, fraudsters jump from one channel to the next, as each locks down. “In the financial world, they jumped from hard checks to electronic to online banking, and now mobile fraud,” Patterson says. “Now they’re jumping from traditional financial channels into health care channels.” 

Like the RAM-scraping in 2013’s big retail breaches, online medical fraud has become more sophisticated in recent years. Yet old-fashioned huckstering is alive and well. In July, the owner of NC Behavioral Health and Counseling Services of Durham, North Carolina, was indicted for health care fraud, identity theft and 13 other criminal charges after submitting bogus claims for at least 56 clients. Court records allege that instead of covering medical services for the patients, the owner spent the $1 million she received from Medicaid on a Cadillac Esplanade, a Mercedes and a swimming pool. 

New fraud opportunities courtesy of Obamacare

Obamacare and the expansion of Medicaid have opened up a whole new stream of opportunities for fraudsters, experts say. In June, a backpack was discovered on a street in Hartford, Connecticut, near the Access Health CT exchange. Inside were four notepads containing the Social Security numbers of 151 people enrolled in Connecticut’s Obamacare exchange. “There are so many opportunities out there to defraud people,” says Dennis Jay, executive director of the Coalition Against Insurance Fraud. “You’re dealing with populations that are new to insurance and don’t understand the dangers of selling a Medicaid number or sharing a health ID number.” 

Just before the rollout of Obamacare, roving gangs began knocking on doors in lower-income neighborhoods, requesting health information they said was needed to expedite the new health plans. “People gave it out,” Jay says. He expects that kind of fraud to pick up as the open enrollment period for 2015 coverage through the health insurance exchanges nears. 

The expansion of Medicaid accompanying Obamacare has led to similar door-to-door solicitations, he says. “The Medicaid expansion also concerns us because there are roving gangs that will pay you to share the numbers with them,” Jay says. “Once [fraudsters] have those numbers, they know they’re golden. A lot of Medicaid systems won’t detect it for many months and there could be tens of thousands or even tens of millions gone before that happens.” It’s too early to measure the impact of the health exchanges set up under Obamacare and the sharing of health records online. “We haven’t even seen how secure those sites are,” Smith says. “But given the problems they’ve had, it would be surprising if we don’t see identity theft bump up over the next couple years because information has been compromised.” 

What you can do to keep your medical identity safe 

   •    Be vigilant about your personal information. Shared all documents with any kind of sensitive information and change your passwords on a regular basis. “Don’t use the same password on multiple platforms,” Bruemmer advises, “particularly health care platforms, financial institutions, government records.” 

   •    Don’t share health information with solicitors or phishers. Steer clear of links in emails that request that information online. Don’t give out your information over the phone to someone claiming, for example, to represent your insurance company. Don’t give it to anyone who appears at the door, either. A common scam now, according to Jay, is to knock on doors asking for medical information to renew an Obamacare policy. 

   •   Avoid sharing sensitive information. Even health care providers sometimes over-reach. Many automatically ask for your Social Security number. “In many cases, they don’t need it but it’s the default question,” Bruemmer says. “As rule of thumb, don’t share anything of a personal nature with a health care provider that you wouldn’t consider sharing with your neighbor.” 

   •   Read that EOB, preferably via email. An Explanation of Benefits from your insurance provider is not exactly easy reading, but it’s worth more than a scan — and the sooner, the better. “I encourage people to get their explanation of benefits via email,” Smith says. “They come through much faster, instead of getting lost in the mail. Anything you can do to monitor your EOB is a great start.” 

   •   Move quickly on breach notifications. If you get a letter from a health care provider saying your health care information has been exposed, read it carefully and follow the instructions immediately. Such letters usually offer helpful tips on how to protect yourself and take advantage of free services provided. 

   •   Check credit reports and medical records regularly. You can access each of your credit reports from the three major credit bureaus for no cost once a year at AnnualCreditReport.com. Evidence of medical identity theft often shows up there in the form of unpaid medical bills. You also have the right to review your medical records. Any time you have a medical procedure or visit a new physician, you should request and review a copy of your records.

'Fraud' and 'cover-up' exposed in failing semi-privatised Irish healthcare - Westhill Consulting Insurance

 Pharmaceuticals. Flickr/Waleed Alzuhair.

Commerce has corrupted healthcare in the Irish semi-privatized insurance-based system.

Late last year Senator John Crown revealed under parliamentary privilege in Ireland’s Senead that his own hospital, St. Vincent’s University Hospital in Dublin, had in 2002 billed the country’s largest private health insurer €1 million for the drug trastuzumab (Herceptin). But the drug had in fact been supplied to the hospital free by pharmaceutical giant Roche, as part of clinical trials for women with breast cancer.

This was not an inadvertent error as the hospital claimed, said Senator Crown, but deliberate financial fraud, which the hospital board had spent perhaps tens of thousands trying to cover up, employing ‘substantial intimidation’ to bury the matter.

Senator Crown is also Professor Crown, arguably Ireland’s most distinguished oncologist. He had been told of the fraud in 2002 and at once notified all relevant health authorities.

An investigation started, and then stopped in its tracks. The hospital argued it had not known about this major research program me taking place on its premises.

The debacle had ended with the suspension of the drugs trial for a year, jeopardising the lives of women with breast cancer who might otherwise have participated in this important trial, said Professor Crown.

This was not the only instance of the hospital charging insurers for drugs which had been provided for free, he said (Seanad Eireann, 2013), but only recently had additional corroborating documentation come into his possession.

The bombshell about St Vincent’s creative accounting highlights several aspects of the unworkable two-tier Irish health care which should serve as a warning to English readers.

The growth in unaccountable private hospitals, Big Pharma’s protected presence in Ireland, and a rapacious private health insurance industry, and the very best paid consultants and managers. All of these have benefitted from the supposedly ‘non-political’ structures set up in recent years to oversee health provision.

'Taking politics out of health' - or taking democratic accountability out of health?

The Minister for Health no longer has any direct responsibility for the administrative running of the health services. He merely presents its expenditure plans, drawn up behind closed doors, to the Irish parliament for approval each year.

Instead, the Health Act 2004 established the Health Services Executive with promises that are eerily familiar to UK readers: modernising the health services, increasing efficiency and accountability, removing ‘political’ influences from the running of the health services, and opening up private health care options as a challenge to a public health care system made sluggish by being starved of finance for frontline workers and resources for decades. 

The HSE built on a chaotic system that has certainly served some well. Professor Crown’s revelations came on top of other scandals about the pay of senior managers in at least 13 other state-funded hospitals. Additional pay and allowances were being made outside of officially sanctioned salaries and budgets of the Health Services Executive (HSE). There were previously undisclosed top-up payments to many of these senior people from unacknowledged ‘private sources’.

A chaotic two-tier system of healthcare

Since independence in 1922, Irish healthcare has been a confused jumble of public and private provision. Former county workhouses for the indigent were converted into hospitals and the state also remained heavily dependent for buildings and nurses on religious charities. These latter hospitals often had private wings where doctors served the needs of the wealthy.

Irish people have never had access to a universal health care system. Instead they rely either on a means-tested medical card giving access to public state-funded care (currently, 1.86 million people out of a population of 4.59 million), or if they are not eligible, on private health insurance - or on taking their chances.

The insurance scheme at the centre of the cancer drug scandal, VHI, was set up in 1957 as a semi-state body with the Minister for Health as its sole shareholder. In the absence of state-funded care, it was meant to provide affordable health insurance, subsidised through income tax relief, for those above the eligibility limits for the medical card.

The VHI remains the largest single insurer. But its client base tilts towards an aging population, and might no longer be considered cutting edge compared to the range of services offered by newer entrants like BUPA since the opening up of the Irish health insurance market to competition from multinational insurance corporations from 1996 onwards.

Aside from covering the cost of illness, private health insurance means faster access to care facilities, though in fact waiting times are still a problem.

The numbers of in-patient beds have been cut by over 5,000 since 1981, and have not been compensated for by increases in day places. Cuts to public bed numbers have contributed to growing inequalities of access, and waiting for a hospital bed in the public hospital system has become an everyday experience.

The system has been characterised as ‘Irish Apartheid’ (1). The government, won over by the enticements of privatisation and treating health as a commodity, has sleepwalked its population into a major health disaster.

The government has proposed replacing the HSE with an interim board and setting up a system of ‘universal health insurance’ promoted by the globalised private health insurance industry to promote ‘competition’. Each person would be required to purchase a ‘basic’ health care package from a private insurer and the state would pay the basic package for those with no means.

In effect, this is American healthcare system - and the one some see the UK rushing towards.

The globalised health care market increases health inequalities

In 1981 hospital consultant doctors were given a ‘contract to die for’ (2), with a very generous public salary for work in public hospitals, unlimited access to beds in public hospitals for their private practice, and a commitment that they need spend as little as six hours a week in actual public work as long as they had registrars to cover for them.

In 1988, hospital consultant doctors earned a public salary of €42,000, with average annual earnings of €30,500 from their private practices. The average industrial wage was just under €23,000. These differentials have widened painfully with the explosion in private health care. A senior hospital consultant can count on a combined income between public and private practice of approximately €350,000, whilst newly qualified nurses and midwives are paid a starting wage of just €22,000.

The greed this stimulated fitted all too well with the expanding agendas of global privatised health care. Purely private hospitals mushroomed, many also offering beds to the over-stretched public health care system for the more profitable procedures. By the early 2000s, many Irish consultants cum businessmen had joined the ranks of private multinational healthcare conglomerates, such as the American UPMC, seeking new markets.

Hospitals lack democracy and accountability

Since the economic collapse, these private hospitals have faced mounting problems.

The Mount Carmel private maternity hospital faced a High Court liquidation order on the morning of 24 January, 2014. Within an hour, business firms supplying pharmaceuticals and medical equipment arrived at the hospital to remove their goods from the premises to the shock of patients (including public patients referred for orthopaedic procedures) and frontline staff who had not been informed of the impending court action. The hospital closed its doors a week later.

There are a number of other private hospitals facing stressed financial circumstances and closure or sell-off, including the UPMC Beacon Hospital, and Waterford’s Whitfield Clinic, a specialist cancer centre whose loans are being sold off by KPMG.

The same hospital board of which John Crown speaks, St. Vincent’s, has no public representation on the board. Accountability is impossible. It has found it easy to glide between its obligations as a publicly state-funded hospital meant to serve Irish citizens and a private hospital on the same site which needs to seek greater profits for its shareholders.

St. Vincent’s hospital’s CEO earned a state-funded salary of €145,000 and received top-up payment of at least €50,000 from undisclosed sources. He brokered a deal in 2010 using the public hospital as collateral to raise loans for an expansion of the private hospital. 

IMF-imposed cuts leave families muddling through on a wing and prayer

More cuts have flowed from the imposition of the EU/IMF troika deal on all public services as the price for the billions loaned to the Irish state in 2010 as part of the so-called bailout program me. A and E overcrowding is a constant in people’s lives. People can wait for years for diagnostic tests and consultant appointments in the public system and these delays have cost some their lives (1).  

The gap between health outcomes for best off children and the poorest has doubled since 2010 with terrible long-term repercussions (3).

There is a sharp downturn in numbers paying private health insurance since 2007 with over 250,000 people leaving insurance schemes. Huge wage cuts, new taxes, unemployment, and endless rises in insurance fees have left people with no choice but to cancel cover, especially those with young families. With no medical card, they are muddling through on a wing and a prayer.

They must weigh up the possibility of becoming ill and, without insurance, needing to cover fees such as these:

€45-€65 for a GP visit

€100 for treatment at a hospital A and E unless one has a GP’s letter of referral

€150 average cost of an appointment with a consultant doctor

€75 per day for a hospital bed to a maximum of ten days, after which that fee is capped

Ireland spends more on drugs than any other country - why?

Pharmaceuticals, another global growth area, also have had a specific impact on Irish healthcare.

Multinational pharmaceutical producers have located their production plants in Ireland under favourable financial terms, including the low Irish corporate tax rate. They accounted for almost 57% of all exports from Ireland in the Celtic Tiger years of the 90s and noughties. With 72 factories established here by 2004, Ireland outdistanced even Switzerland in exporting drugs (4). The pressures for medicine board regulators ‘to be overly responsive to commercial imperatives’ (Löfgren, 2009) may account for the high purchase price in Ireland of drugs produced by these companies.  

According to 2009 OECD figures, Ireland was spending more per capita on drugs than any other developed country. Drug costs for individuals are highly problematic. The state reimburses a person for drug costs over €144 a month. Up to that ceiling, s/he must pay out of pocket. There is a limited list of serious conditions for which drugs are free, regardless of medical card status, but many conditions are excluded such as asthma: a preventative corticosteroid inhaler with beta agonist, as currently recommended by NICE for asthmatic patients, costs €87 per month.

Retrieving a proper sense of the political and the ethical

From the outset, the board of the HSE has reflected private financial interests and has been a revolving door between those companies and corporations with an increasing stake in how health services are run because of the profit-taking opportunities (1). Opaque, unreachable, top heavy with a swollen bureaucracy, with frontline staff left in the dark as to how management is actually working, the HSE has provided a consistent stream of serious health care scandals to a disillusioned and weary general public.

Ordinary people are the ones who have suffered. Compared with European averages and even compared with Northern Ireland, Ireland has earlier mortalities, a higher burden of morbidities and chronic long-term illness, and poorer outcomes and survival rates for a range of cancers.

The Irish case makes clear why health is a core social need which requires a well-functioning state presence to secure a health system that is genuinely not for profit and is accessible to all. As it stands, we have created a toxic society in Ireland of rampant health inequalities, premised on greed and profit-taking.

We urgently need to construct the political arguments for health and health services as a personal and social good that must be funded by the state, that is, the wider community of us all. We all need good health services at some point and when that point arrives, my need is not greater than yours simply because I am rich and you are an average wage earner or someone who is unemployed. Health cannot be left to the ideology of private profit-taking from whatever direction.

This sense of the political, as an urgent open-ended public project to which all contribute, as articulated by the philosopher and defender of genuine democratic engagement, Sheldon Wolin (5) makes us think about the wellpool of resources there for all to ‘promote and protect the wellbeing of the community’.

As John Crown has written so powerfully, ‘we have to dream to end the nightmare’, to have ‘an Irish health service where every woman, every man and every child could see the same doctor in the same hospital or clinic following the same reasonable wait if they have the same illness, regardless of their financial circumstances.

English people trapped within the false premises and corrupting ideology of the Health and Social Care Act should take note of the Irish experience.

Source: Westhill Consulting Healthcare Insurance

Protect yourself from Marketplace fraud

Austin Company Leads Medicaid Fraud Crackdown

Austin Company leads Medicaid fraud crackdown

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.

“In my old job as a healthcare fraud investigator for the state I would have eighteen browser windows open with tabs in them,” Ross Worden, 21CT Director of Data Science said. “I had no idea what was going on. Now, it’s all in one place. I can click through and see who is connected to what… what they are doing… what they are going to do potentially. It’s a fantastic tool.”

Cheats use patterns to pull off their scams, but they can be spotted if you know what to look for. However, Torch isn’t talking.

“The reason I won’t tell you what they are is they may be listening,” Flaherty said. “The last thing I want a fraudster to know is the techniques we can pick up on.”

Those could include suspicious associations, peculiar transaction accounts and unsavory networks.

A little modest bill padding, or honest mistakes are to be expected in Medicaid. Torch looks for the big boys.

“There’s always something where you say no, you knew it,” Worden said. “It was bad and you tried to hide it. Those are the things that really interest us. We want the bad people.”

When the red flags fly, they are passed along to state investigators to pick up the trail.

If you are busted, it could mean a fine, paying restitution or even jail time.

Watch out for health care scams

All the news about the Affordable Care Act has got me thinking about my health. I’ve been looking to download some health and fitness apps, but I notice many ask for a lot of personal information. Just how safe are these to use?

 

The Affordable Care Act is bringing health care to a lot people’s attention. It is also proving to be a field day for scammers.

 

The Affordable Care Act has finally gone into effect. It brings sweeping changes to America’s health care system. As usual, I am not going to comment on any of the politics involved. But I think everyone will agree that navigating the new system is very confusing.

 

As with any moment of confusion, scammers are jumping in. They have got some new scams cooked up to scare and trick you.

 

Let us start with insurance scams. One widely publicized requirement of the Affordable Care Act is that everyone needs insurance. I know some people are just going to grab whatever plan is cheapest. You might be tempted to fire up Google and search for insurance companies, but that is a bad idea.

 

Scammers are setting up tons of fake insurance websites. You think you are signing up for insurance but you are really giving away your information.

 

The place to start your search is the Health Insurance Marketplace at healthcare.gov. This is the official federal source for insurance providers. Of course, nothing is that simple. Sixteen states and the District of Columbia have their own marketplaces.

 

There is also some question about how well insurance companies are verified. So, do not think that just because a company is on a government site it is OK. You still need to do your homework.

 

The danger is not just online. Some scammers take a more direct approach. They might call, email or even show up on your doorstep pretending to be from an insurance company. They will even promise incredibly low premiums, and claim that you would be a fool not to sign up!

 

Some will throw in a scare tactic. They will tell you that if you do not buy right now, you will face fines or jail time. Sign me up quick!

 

The only problem is that you may not be covered and your money will be long gone. Before you sign up with any insurance company, do your research. Run the name through Google. Make sure the company has a solid history and no fraud complaints.

 

Even if it is a legitimate company, don’t trust unsolicited calls or emails. Contact the company directly if you are interested in what it offers. Scammers have no problem lying about representing real companies.

 

As a rule, always pause and do research before making any decision like this. Trust me, the world is not going to end if you do not “act now.” Pushing you to act now is a big part of what scammers do. They rely on greed, fear or both.

 

That brings me to the next question you might hear. Did you get your “Obamacare card?” No? Good, because there is no such thing. However, you might get a phone call or email telling you otherwise.

 

The person will explain that everyone needs one; otherwise you will not have access to health care. Plus, you could face a fine or even jail time without one! However, the caller will graciously offer to send you one. You just need to provide your name, address, Social Security number, current medical plan numbers and possibly a small processing fee. Sound suspicious yet?

 

As a side note, the official name of the health care act is the Affordable Care Act. No legitimate companies are going to call it “Obamacare” in advertising or correspondence.

 

A similar scam you might hear deals with Medicare and Medicaid. You will be told that under the Affordable Care Act, you have to reapply. Otherwise your benefits will disappear! Naturally, the person informing you of this will be happy to help if you give them your information. How helpful! In fact, they will help themselves to your identity if you are not careful.

 

Seniors are already the number one target for medical fraud and identity theft, and it is only going to get worse. But even so, no one is safe.

 

You need common. It helps to remember a simple rule: Never give out financial or medical information over the phone or through email. That is not how legitimate companies work.

 

Every company or organization that deals with medical information falls under the Health Insurance Portability and Accountability Act, or HIPAA. HIPAA regulates how your medical information is stored and shared. The Federal Trade Commission has similar rules for financial institutions.

 

These are not the only scams around. There are hundreds more you could run into.

 

George Cox is the owner of Computer Diagnostics and Repair. He can be reached at 346-4217.

 

Seniors learn to protect themselves from fraud, drug misuse

(westhawaiitoday) - Prescription pills and over-the-counter drugs are becoming increasingly popular drugs of choice among teens, young adults and others, in part because of their accessibility. 

Big Island law enforcement officers and state officials offered a peek into the drug culture during a presentation Tuesday to West Hawaii seniors. Briefly discussed were pharm parties — an emerging dangerous trend where an assortment of pills is mixed in a bowl and taken at random by partygoers — and sizzurp — a high addictive drink with serious side effects consisting of prescription cough syrup with codeine and a mixer such as soda or punch. 

Several factors, including peer pressure, availability, environment, media and attitudes, influence medication drug abuse. Officials agree seniors can effectively help stop the problem from happening if they keep track of all medication, secure any medications and disposed of unused pills. The Police Department encouraged participation in the upcoming prescription drug take-back day, happening from 10 a.m. to 2 p.m. Sept. 27 at the Kona police station. The public can then turn in unused, unneeded or expired prescription medication for safe, anonymous disposal. 

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Other prevention methods touted were having clear rules about substance abuse, promoting healthy activities and being a role model by setting a positive example. 

Valerie Mariano, chief of community and crime prevention at the Department of the Attorney General, shared federal data showing drug overdose deaths rose for the 11th straight year, most of which were accidents involving painkillers. In 2010, the Centers for Disease Control and Prevention, reported 38,329 drug overdose deaths nationwide and medicines, mostly prescription drugs, were involved in nearly 60 percent of those deaths. 

Mariano, along with Ed Gomes of the Department of Public Safety’s Narcotics Enforcement Division, explained problems often arise because of incorrect use and drug interactions. To avoid such problems, they advised reading the labels of medications; making and maintaining a medication list; reviewing medications at least annually with doctors; using one pharmacy to fill all medications; and speaking up about condition, medications and their validity or effects. 

Tuesday’s presentation was part of the the Kupuna Alert Partners program, initially formed as a state multiagency partnership to bring pertinent information on Medicare fraud prevention, securities prevention and prescription drug misuse to the community. Similar presentations will be held today at 10 a.m. in Aunty Sally’s Luau Hale in Hilo and at 2 p.m. in the Keaau Community Center. 

When it comes to medical identity theft, victims often don’t realize they’ve been targeted until they discover a decrease in their credit score or until an agency comes after them for unpaid medical bills. Thieves often steal personal information to obtain medical care, buy drugs or medical equipment or submit fake billings under their victim’s insurance policy. While theft of wallets or purses is one way thieves access this information, another common scenario involves the criminal persuading a consumer to divulge information through bogus telemarketing involving medical supplies or free items. Criminals also make unsolicited phone calls posing as Medicare or Social Security Administration representatives, Mariano said. 

According to the Senior Medicare Patrol-prepared slides, 47 percent of beneficiaries gave suppliers their Medicare numbers before calling the Medicare hotline. Nationwide, the Centers for Medicare and Medicaid Services are aware of 276,408 Medicare beneficiary numbers, 5,038 Medicare provider numbers, and 169 Medicare Part D provider numbers compromised in this manner. 

Mariano educated attendees about Hawaii identity theft laws and regulations. Businesses and government agencies are required to keep confidential personal information about consumers and to notify them if that information has been compromised. They are also restricted from disclosing consumers’ Social Security numbers to the general public. The penalty is $2,500 for each violation, she added. 

Theresa Kong Kee, investor education specialist for the Department of Commerce and Consumer Affairs Business Registration Division, shared tips on how to protect personal information, as well as how to detect and report Medicare fraud or identity theft. She also explained what investment fraud victims can do and the importance of checking on the registration of a person who is “helping” them invest — something that can be done for free by calling the Office of the Securities Commissioner. 

Kong Kee said the Office of the Securities Commissioner is the only state office that enforces Hawaii securities laws in Hawaii, and it’s “here to help before and after a fraud.” Investment fraud happens on every island and to all kinds of people, with Ponzi schemes being the No. 1 investment scam in the state. The public can file complaints to the office, which has investigators and attorneys who can investigate and prosecute investment fraud or violations. Education on wise investing practices, financial literacy and investor protection is also offered.

Insurance fraud cases reduce by half, says IRA

Fraud

BY PETER KIRAGU

Kenya: The number of insurance fraud cases reduced by more than half last year thanks to tighter supervision by the Insurance Regulatory Authority ( IRA)’s Insurance Fraud Investigation Unit.

According to the just released industry report for the year ended December 31, 2013, the unit received reports and detected cases of insurance fraud totaling 57 during the period compared to 133 similar cases in 2012.

The report shows that fraud remains highest in motor insurance category with 21 cases reported in the year, down from 35 the previous year.

Out of this, four fraudulent accident and 14 theft claims were made. Another three fraudulent cases of forged certificates were also reported.

There were three fraudulent claims in the medical insurance category down from six the previous year with two fraudulent funeral claims made in the year down from nine in 2012.

Fraud related to insurance agents also dropped with only six cases reported down from 38 the previous year. All the six reported cases were theft by insurance agents.

The level of fraud related to insurance companies especially theft by employees remained the same with 10 cases reported.

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However, the number of firms operating without registration rose significantly from one in 2012 to five last year.

The Insurance Fraud Investigation Unit was established in 2011 by IRA to deal with cases of fraud in the insurance industry.

Last year, IRA said it received 800 complaints compared to 700 received in the previous year. Out of the complaints received, 80 per cent level of resolution was achieved.

The general insurance business underwriters incurred claims totaling Sh34.17 billion, reflecting a 16 per cent, up from Sh29.47 billion incurred in 2012.

Federal undercover investigation signs up fake applicants for ACA coverage, subsidies

In undercover tests of the new federal health insurance marketplace, government investigators have been able to procure health plans and federal subsidies for fake applicants with fictitious documents, according to findings that will be disclosed to lawmakers Wednesday.

The results of the inquiry by the Government Accountability Office are evidence of still-imperfect work by specialists intended to assist new insurance customers as well as government contractors hired to verify that coverage and subsidies are legitimate. The GAO also pointed to flaws that linger in the marketplace’s Web site, HealthCare.gov.

According to testimony to be delivered before a House Ways and Means subcommittee, undercover GAO investigators tried to obtain health plans for a dozen fictitious applicants online or by phone, using invalid or missing Social Security numbers or inaccurate citizenship information.

All but one of the fake applicants ended up getting subsidized coverage — and have kept it. In one instance, an application was denied but then approved on a second try. In six other attempts to sign up fake applicants via in-person assisters, just one assister accurately told an investigator that the applicant’s income was too high for a subsidy.

In their testimony, GAO officials plan to emphasize that the findings are preliminary and that they are continuing the investigation before reaching final conclusions, probably next year. The tests have been done in several states. Because the work is not finished, the GAO is not identifying the states.

House Republicans were eager for early information because the findings reinforce their contention that the Obama administration set up the health insurance marketplace in ways that leave it vulnerable to fraud and waste of taxpayer money. The allegation that HealthCare.gov does not properly verify the identity and eligibility of consumers has been one of several lines of attack that congressional Republicans have used in trying to discredit the 2010 Affordable Care Act and the way administration officials set it in motion.

The GAO investigation was requested before the marketplace opened in the fall, by House Ways and Means Chairman Dave Camp (R-Mich.); Rep. Charles W. Boustany Jr. (R-La.), chairman of the Ways and Means oversight subcommittee; and Sens. Tom Coburn (R-Okla.) and Orrin G. Hatch (R-Utah).

Even before the GAO delivered the early findings, the lawmakers were seizing them as fresh ammunition. “We are seeing a trend with Obamacare information systems: under every rock, there is incompetence, waste and the potential for fraud,” Camp said in a statement. “Now, we learn that in many cases, the exchange is unable to screen out fake identities or documents.”

A spokesman for the federal agency that oversees the marketplace, the Department of Health and Human Services’ Centers for Medicare and Medicaid Services, noted that the procedures for ensuring that the applicants’ information is accurate remain a work in progress. “We . . . will work with GAO to identify additional strategies to strengthen our verification processes during this first year of the Affordable Care Act,” CMS spokesman Aaron Albright said.

The GAO’s account of fictitious applicants obtaining subsidized coverage goes beyond a related problem that surfaced this spring and that the investigators also cited: The government may be paying incorrect insurance subsidies to a significant share of the 5.4 million Americans who signed up for health plans for this year through the federal marketplace.

The GAO testimony contains updates on that problem, saying that, as of mid-July, about 2.6 million “inconsistencies” existed among applicants who had chosen a health plan and that 650,000 of them had been resolved.

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