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The DOJ has announced a pilot program to pay whistleblowers of private insurance plans if their information leads to a settlement or conviction. They have always paid whistleblowers against fed med.
The following two stories are meant to contrast. The first is from UnitedHealth execs and the second is from an article in STAT detailing the horrors of UnitedHealth but the story can be translated to many other insurers as well. UnitedHealth is just the largest so it has a bigger target and causes more harm.
The UnitedHealth execs spouted about how good they are doing for the consumer by utilizing a new commercial insurance plan that uses AI and machine learning to show the most relevant "providers" to the public. Relevant means cheapest. The process will show members an estimated cost for services for each CPT code and public data. Not a word about the care. "Consumers" will be able to read patient reviews which all knows are very meaningful, NOT.
The STAT article details how UnitedHealth games the system of fed med Medicare Advantage. It starts with the Obamacare legislation signed in 2010, who Pelosi said "you'll find out what's in it after you vote for it". This capped how much insurers could be paid which, being for profit, meant they had to look elsewhere for increased profits. The law also started to increase payments for "value care", which no one has ever defined. Value care is thought to mean preventative care so more money is given for that. In order to tap into that pot of money the insurers must have closer collaboration with "providers". They need to purchase the "providers" so they can pay money to themselves and not others. Physicians are also to blame in this. The groups needed money for new EMRs and the the older ones were looking for a way out with more money. The money paid for the practices usually flowed to the older physicians which helped their exit. Also at the same time physicians were pushed into EMR schemes for increased reimbursement which increased burnout and wanting to get out of medicine. UnitedHealth started to get into the MA programs in a big way and purchasing physicians at the same time. They needed the physicians to do the coding and who better to direct what to code than your employer. If you don't do what your employer says they have a private meeting with you and if you still do not go along then you may be shown the door. UnitedHealth has 90,000 physicians either employed of otherwise under their thumb. Physicians working for United have said that their schedules changed soon after being purchased forcing them to see more patients per day so more money for the employer. Then they were told what to code for higher reimbursement even if the codes were erroneous. Could this be fraud? If you went along and were a good coder group bonuses were in the offing. Who would want to be the person to deny more money to your fellow physicians by not coding more? UnitedHealth put coding into an art form, so much so that it published a book on how to code for greater reimbursement. Coders are taught that for each 0.1 in coding equates to $1000 in extra reimbursement. Therefore increase the risk stratification any way you can. Again, I ask the question, Could this be fraud and why is there no significant audits by the feds as to where the money goes. It is believed that this year there will be over $50 Billion in overpayments to the insurers. Could this money go to better use?
On the front of dementia, President Biden wanted and signed the Congress passed Inflation Reduction Act. This is causing a significant spike in Medicare premiums and it will happen just prior to the election. Not a good voting vibe. To counter his error he wants to pay Billion of dollars to private insurers so the increases will not be as bad as predicted. Harris will be negatively impacted by this demento. The administration wants to pay the insurers $15 subsidy plus restrict how much the insurers can raise rates year over year. More regs that would be not needed as well as increasing the debt even more. The law has already caused one of the largest insurers of Part D, Mutual of Omaha, to drop out of the market and will rally hurt the Medicare stand alone plans. I don't understand, if he is too demented to run again, which he is, how can he stay in office. Top
Kaiser Permanente is still the darling of the medical field. Their second quarter numbers show an operating income of $908 million, over $200 million million more than one year ago. Their revenue was $3 Billion over last year and their operating expenses were $4 million more. Their net income was flat but they almost always have more expenses in the beginning of the year.
Crozier Health in Upland, Pennsylvania will end its surgical services at Taylor Hospital in Ridley Park, Pennsylvania. Crozier also four days earlier agreed to sell its for-profit hospitals to a non-profit chain. The largest hospital in the system is only 3.5 miles away from Taylor Hospital. That hospital lost its accreditation for surgical residency programs due to a low surgical volume. Top
Steward Health Care out of Dallas is selling its cattle, oops sorry, chattel physician group Stewardship Health to Rural Healthcare Group, a private equity group out of Nashville. This group takes care of the value (?) portion of fed med. I am sure the cattle will profit in this move, maybe get more hay.
The physicians of India have gone on strike following a stabbing of a resident physician. They want better protection since about 75% of the physicians in the country have faced some form of violence. Top
DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.