Tag Archives: Medicare Advantage Plans

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

UnitedHealthcare Dropping Hundreds Of Doctors From Medicare Advantage Plans

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Dorathy Senay’s doctor had some bad news after her last checkup, but it wasn’t about her serious blood disorder called amyloidosis. Her Medicare Advantage managed care plan from UnitedHealthcare/AARP is terminating the doctor’s contract Feb. 1.

She is also losing her oncologist at the prestigious Yale Medical Group — the entire 1,200 physician practice was axed.

Senay, 71, of Canterbury, Conn., is among thousands of UnitedHealthcare Medicare members in 10 states whose doctors will be cut from their plan network.

The company is the largest Medicare Advantage insurer in the country, with nearly 3 million members.  More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s network of providers.

doc“I have a rare incurable disease and these doctors have saved my life,” said Senay.  “I am in good hands and I will not change doctors.”

UnitedHealthcare has begun telling members about the network changes. But there is now less than two weeks before the Dec. 7 deadline for choosing new coverage next year. Timing is crucial since once they sign up, most Advantage beneficiaries are locked into their plans for the year.  Losing a doctor does not constitute an exception to the rule. Insurers can drop providers any time with 30 days advance notice to members.

Several medical associations are encouraging doctors to appeal the cancelations, which could make it more difficult for seniors to choose a plan in the time remaining.  Neither Medicare, which oversees the Advantage plans, nor UnitedHealthcare would disclose how many providers will be dropped.

The American Medical Association and 39 state affiliates along with 42 medical specialty and patient advocacy groups have urged Medicare chief Marilyn Tavenner to extend the enrollment deadline and require insurers to reinstate the doctors for another year. Medicare has told the Connecticut attorney general that it will not postpone the deadline.

UnitedHealthcare spokeswoman Jessica Pappas said in a written response to questions, “While these changes can be difficult for patients and their doctors, they are necessary to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts.” However, the doctors dropped from Medicare Advantage plans can still treat patients covered under other UnitedHealthcare policies.

The Affordable Care Act phases in reductions in government payments to Medicare Advantage plans — $156 billion over 10 years — to bring the program into line with the costs of caring for seniors in traditional Medicare.

Medicare officials review the private plans every year to make sure they comply with network adequacy and other requirements, but the agency did not approve the reconfigured networks resulting from the new provider cancelations. Spokesman Raymond Thorn said the agency “is currently reviewing UHC and other plans’ provider networks and closely monitoring all areas that have experienced disruptions to ensure that beneficiaries have full, transparent and timely information and access to needed care.”

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UnitedHealthcare Dropping Hundreds Of Doctors From Medicare Advantage Plans