Category Archives: Educational Material

Medicare Advantage billing errors cost taxpayers billions

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medical billsIn the South Florida case, government lawyers have been investigating Humana, Inc. for several years as they try to determine if the company and some of its medical clinics manipulated the complex Medicare Advantage billing system. Humana says it is cooperating with the investigation.

Humana also faces other investigations into allegations that it overbilled the government, including a criminal investigation by the Department of Justice in Washington and a criminal case involving the U.S. Attorney’s branch office in West Palm Beach, Florida, according to court records. Humana spokesman Tom Noland said, “Our original self-disclosure several years ago was made to the criminal division of the Department of Justice, but Humana to our knowledge is not the subject of a criminal investigation.”

Medicare Advantage is a “black box,” added James Cosgrove, who heads health investigations for the GAO, the audit arm of Congress.

“We know what services they say they will provide … but we never know exactly what services are being provided,” Cosgrove said.

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Medicare Advantage billing errors cost taxpayers billions

Feds investigating allegations that Humana Inc. overcharged Medicare Advantage program

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The entrance to the Humana headquarters in Louisville, Kentucky. Brian Bohannon/AP

The entrance to the Humana headquarters in Louisville, Kentucky.
Brian Bohannon/AP

Giant health insurer Humana Inc. faces multiple federal investigations into allegations that it overbilled the government for treating elderly patients enrolled in its Medicare Advantage plans, court records reveal.

The status of the investigations is not clear, but they apparently involve several branches of the Justice Department. The U.S. Attorney’s Office in Miami wrote in a court document filed in March that officials expect that at least one of the probes will be completed and the findings made public “in the next few months.”

The U.S. Attorney’s branch office in West Palm Beach, Florida has opened a criminal case involving overbilling allegations that the government says is similar to the Miami investigation. Meanwhile, the criminal division of the Justice Department in Washington has reviewed fraud allegations against the company, according to court records.

Humana, which insures more than 2 million people through the Medicare Advantage plans, is also the target of two Florida whistleblower civil lawsuits that allege similar overcharges.

Federal officials disclosed their legal actions in a series of documents unsealed April 30 in one of the whistleblower suits. That suit alleges that a doctor at a clinic in South Florida inflated billings for two dozen or more Humana patients. The case, filed in September of 2010, was unsealed in federal court in Miami earlier this month. The whistleblower added new allegations of overbilling to the Miami lawsuit on Wednesday.

Humana acknowledged the unsealing of the Miami case in a May 7 Securities and Exchange Commission filing, saying it “was continuing to cooperate with and respond to information requests from the U.S. Attorney’s Office.” Humana disclosed in 2012 SEC filings that federal officials were seeking documents “relating to several matters including the coding of medical claims,” an admission that was reported at the time. But the company has offered no details.

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Feds investigating allegations that Humana Inc. overcharged Medicare Advantage program

Congresswoman Asks GAO To Investigate Medicare Advantage After Complaints

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Congresswoman Rosa Delauro

Congresswoman Rosa Delauro

HAMDEN — About a dozen elderly people gathered in a conference room at Hamden Government Center on Friday to talk about their anger and frustration since UnitedHealthcare announced last fall it would cut thousands of doctors from its Medicare Advantage network.

They were further incensed when UnitedHealthcare and Yale-New Haven Health System did not reach a contract agreement, meaning the New Haven hospital will be dropped from the insurer’s Medicare Advantage network starting April 1.

Medicare Advantage is the version of government-funded Medicare that is offered by private insurers as an alternative, often with additional benefits and lower out-of-pocket expenses than traditional Medicare. The plans have been more expensive to federal taxpayers, on average, than traditional Medicare and the Affordable Care Act is scheduled to narrow the gap. As a result, insurers are offsetting the loss in government payments by changing benefits, premiums or physician networks.

The gathering was hosted by Congresswoman Rosa DeLauro, D-New Haven, who said she is asking the U.S. Government Accountability Office to investigate criteria for Medicare Advantage plans as set by the federal Centers for Medicare and Medicaid Services. DeLauro wanted to hear the experiences of people who have called her office to complain after UnitedHealthcare cut its Medicare Advantage physician network last fall.

The insurer has not said how many doctors it planned to eliminate, but the Fairfield County Medical Association has said it is 810 primary care physicians and 1,440 specialists across Connecticut.

“In light of the recent UnitedHealth Group network reductions, I am concerned that the oversight of Medicare Advantage plans may be lacking,” DeLauro wrote in a March 7 letter to Gene L. Dodaro, head of the GAO. UnitedHealth Group is the parent company of UnitedHealthcare.

She added that she is interested to learn how the Center for Medicare and Medicaid Services reviews whether seniors are receiving the quality care they deserve.

In addition to network cuts announced last fall, UnitedHealthcare and Yale-New Haven Health System failed to reach a contract agreement. As a result, the insurer said in February that Yale-New Haven will be cut from its Medicare Advantage network after March 31, with two exceptions. Bridgeport Hospital and Greenwich Hospital will remain in network. Other hospitals, such as Yale-New Haven and the Saint Raphael campus in New Haven, will be out of network starting April 1, and customers will face higher out-of-pocket expenses as a result.

“I’m 93. I don’t need this,” said Edwin R. Abrams, who was born in New Haven and has lived in the city his entire life except for three years in the Air Corps during World War II. He doesn’t want the hassle of going to Bridgeport Hospital instead of Yale-New Haven, which UnitedHealthcare suggests patients do.

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Congresswoman Asks GAO To Investigate Medicare Advantage After Complaints

Medicare Advantage plans to pay Central Ohio Primary Care to keep patients out of hospital

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Advantage Plans title5The largest independent physician group in Central Ohio will get bonus payments for keeping the frailest patients well and out of the hospital under a new deal with five private Medicare Advantage plans.

Central Ohio Primary Care Physicians Inc. will get a fixed monthly payment for patients in the pilot program, plus a share of the savings from actuarial estimates of that group’s 2014 medical expenses. The plans also have agreed to pay for sending patients directly to a high-acuity wing of a skilled nursing facility without the usual requirement for a three-day hospital stay.

The average hospital stay costs at least $10,000, said Dr. William Wulf, CEO of the 270-doctor group. The practice’s hospitalists – specialists who follow patients through inpatient stays – say about one-fourth of patients admitted could have been cared for in a less-costly setting, but regulations and existing payment incentives encourage the hospitalization.

“What if that hospitalist was in a shared savings program for that $10,000?” Wulf said. “That’s where we need to go, that’s where we’re going with population health.”

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Medicare Advantage plans to pay Central Ohio Primary Care to keep patients out of hospital

Missouri regulators lead multistate, market conduct investigation of Humana

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Humana Insurance agrees to $4.5 million settlement and change in business practices

Jefferson City, Mo. – The Missouri Department of Insurance today announced that a regulatory settlement agreement has been reached with Humana Insurance Co. Missouri regulators led a multistate market conduct investigation of Humana in collaboration with regulators in Mississippi and Wisconsin. In the settlement, Humana agrees to pay $1.8 million in fines that will be divided among 10 states and to establish a $2.7 million consumer restitution pool.

The multistate market conduct investigation of the company began in 2012. The investigation was based upon a referral of a single complaint that was filed by a small employer with the Missouri department’s consumer affairs division. The investigation found that Humana Insurance Company was requiring some employers, who purchased small group medical insurance, to also purchase a group life insurance product. In the settlement, Humana agreed to make business reforms to include notifying employers and insurance agents that the additional purchase of life insurance is not required. Humana also agreed to set up a $2.7 million restitution pool to provide refunds for employers who were required to purchase the group life product.

“Policyholders should be able to choose individual insurance products without insurers bundling products together” said Missouri Insurance Director John M. Huff. “I am pleased our team was able to collaborate on a settlement with multiple states to benefit consumers.”

Missouri will receive $390,886, paid to the Missouri State School fund. Other states that will benefit from the settlement and fine are Alabama, Arkansas, Georgia, Mississippi, Montana, North Carolina, Tennessee, Utah and Virginia.

In market conduct exams and investigations, the Department of Insurance reviews insurance company practices regarding the treatment of policyholders. This includes the way premium rates are charged, the way insurers handle claims and other responsibilities under state law. These reviews can result in refunds for consumers, fines and corrections in business practices, as well as other remedies. In the last five years, Market Conduct enforcement actions have generated nearly $20 million in payments from insurance companies. The money goes toward refunds for consumers, general revenue and the Missouri State School Fund.

Consumers who have complaints or questions about life and other types of insurance, can call the department’s Insurance Consumer Hotline at 800-726-7390 or by visiting insurance.mo.gov.

About the Missouri Department of Insurance, Financial Institutions & Professional Registration

The Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) is responsible for consumer protection through the regulation of financial industries and professionals. The department’s seven divisions work to enforce state regulations both efficiently and effectively while encouraging a competitive environment for industries and professions to ensure consumers have access to quality products.

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Missouri regulators lead multistate, market conduct investigation of Humana

Humana to pay $1.8 million fine

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February 14, 2014 4:38 pm

Humana Insurance Co. has agreed to pay $1.8 million in fines and $2.7 million in restitution to Missouri and other states resolve complaints about its sale of small group health insurance.

The Missouri Department of Insurance alleged that Humana required small employers to buy group life insurance in order to get small group health coverage. Such bundling violates insurance regulations. Ten states will divide the fine. Missouri regulators led the investigation with regulators from Wisconsin and Mississippi.

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Humana to pay $1.8 million fine