Tag Archives: Medicare Advantage

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

Not too late for certain Medicare beneficiaries to make changes

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Although Medicare’s annual Open Enrollment period has ended, it’s not too late for certain Medicare beneficiaries to make changes for 2014.

Between Jan. 1 and Feb. 14 each year, people currently enrolled in a Medicare Advantage plan who wish to return to Original Medicare can disenroll from their Medicare Advantage plan, return to Original Medicare, and join a Part D drug plan. (In western Nevada County, the only Medicare Advantage Plan in 2014 is the AARP MedicareComplete SecureHorizons HMO.)

If beneficiaries who qualify for the Medicare Advantage Disenrollment Period decide to make this change, their new plan becomes effective the first day of the month following their enrollment request.

Anyone in need of assistance choosing a new plan for 2014 is welcome to make a free HICAP counseling appointment by calling the HelpLine office at 530-273-2273.

HICAP is a nonprofit organization that provides free, unbiased, one-on-one counseling to Medicare beneficiaries, including people who are new to Medicare.

Karin Hofland, Nevada County regional coordinator

HICAP Services of Northern California

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Not too late for certain Medicare beneficiaries to make changes

Minnesota attorney general asks U.S. to investigate Humana

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Karen MerrickMinnesota Attorney General Lori Swanson said patients and doctors are having “significant problems” with Humana.

Minnesota Attorney General Lori Swanson is asking the federal government to investigate Humana’s Medicare Advantage policies after uncovering what she said were “significant problems” reported by Minnesota patients and medical providers.

Affidavits gathered from 25 Minnesotans showed a pattern where Humana denied claims for medical services required by law, overcharged for co-payments and coinsurance, and failed to disclose the providers that are in the network, she said. Swanson’s office also found that Humana didn’t follow procedures laid out by federal regulations for patients to appeal their cases.

“They were stringing people along, taking months to get back to people,” she said. “Oftentimes, it took the intervention of our office — and oftentimes we had to write multiple times.”

Humana, based in Louisville, Ky., is one of the nation’s largest health care insurers in Medicare Advantage, a private policy that covers seniors and those with disabilities. Humana has been doing business in Minnesota for more than 10 years, and provides insurance coverage to more than 100,000 residents through various types of Humana Medicare Advantage plans, including a plan for prescription drugs, according to a company official.

Humana spokeswoman Kate Marx said in an e-mail that the insurer has not been notified of the complaint by the Minnesota attorney general’s office or by federal regulators.

“We take this very seriously and are working to identify the facts,” Marx said.

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Minnesota attorney general asks U.S. to investigate Humana

MN Attorney General Asks Feds To Investigate Humana

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ST. PAUL, Minn. (WCCO) – Minnesota Attorney General Lori Swanson says a federal investigation is needed to look into business practices at one of the nation’s largest private Medicare insurers.

On Friday, Swanson sent a massive file of complaints against Humana to the federal agency charged with overseeing that part of Medicare.

She’s asking the Centers for Medicare & Medicaid Services (CMS) to look into more than 27 complaints on file.

For the past couple of years, Humana policy holders in Minnesota have complained of improper denial of coverage, overcharges for co-payments and failure to follow the required appeals process.

Kentucky-based Humana provides private Medicare insurance coverage to more than 100,000 Minnesota seniors.

This investigation into Humana’s alleged wrongdoing has been going on for a couple of years, Swanson asserts. It stems from both consumer and medical provider complaints from across the state.

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MN Attorney General Asks Feds To Investigate Humana

Minnesota wants CMS to investigate Humana’s Medicare Advantage plans

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AG Lori SwansonMinnesota Attorney General Lori Swanson is asking the CMS to investigate Medicare Advantage plans offered by Humana and has presented regulators with more than 25 affidavits of complaints from beneficiaries.

The affidavits allege, for instance, that Humana denied reimbursement for services that it is required to cover for all Medicare beneficiaries—including diagnostic ultrasounds, mammograms and care in a skilled-nursing facility for a stroke patient.

The letter also said, among other complaints, that the Louisville, Ky.-based insurer created confusion by not adequately disclosing which providers were in-network and does not comply with required appeals processes.

The complaints come at a time when the popularity of Medicare Advantage plans has been escalating. And Minnesota has the highest percentage of Medicare beneficiaries enrolled in an MA plan, at 49%—compared with 28.8% of beneficiaries nationwide, the letter said. Humana has 17% of the Medicare Advantage market in Minnesota, according to Swanson’s office.

Swanson wrote that she was asking the CMS to pursue an investigation because states do not have the authority to enforce Medicare Advantage plan rules and make benefit determinations.

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Minnesota wants CMS to investigate Humana’s Medicare Advantage plans