Whistleblowers: United Healthcare Hid Complaints About Medicare Advantage

Whistleblowers: United Healthcare Hid Complaints About Medicare Advantage
By Fred Schulte
Kaiser Health News
July 28, 2017

United Healthcare Services Inc., which runs the nation’s largest private Medicare Advantage insurance plan, concealed hundreds of complaints of enrollment fraud and other misconduct from federal officials as part of a scheme to collect bonus payments it didn’t deserve, a newly unsealed whistleblower lawsuit alleges.

The suit, filed by United Healthcare sales agents in Wisconsin, accuses the giant insurer of keeping a “dual set of books” to hide serious complaints about its services and of being “intentionally ineffective” at investigating misconduct by its sales staff. A federal judge unsealed the lawsuit, first filed in October 2016, on Tuesday.

The company knew of accusations that at least one sales agent forged signatures on enrollment forms and had been the subject of dozens of other misconduct complaints, according to the suit. In another case, a sales agent allegedly engaged in a “brazen kickback scheme” in which she promised iPads to people who agreed to sign up and stay with the health plan for six months, according to the suit.

Though it fired the female sales agent, United Healthcare concluded the kickback allegations against her were “inconclusive” and did not report the incident to the Centers for Medicare & Medicaid Services, according to the suit.

Asked for comment on the allegations in the suit, United Healthcare spokesman Matt Burns said: “We reject them.”...

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Obamacare Isn’t The Problem…It’s The Insurance Companies

Primary Care Doctor Explains: “Obamacare Isn’t The Problem…It’s The Insurance Companies”
Posts by cpowell
Blue Dot Daily
July 15, 2017

With premiums increasing for those with coverage through the ACA marketplace, a lot of people are criticizing Obamacare. But many doctors and healthcare professionals are saying that isn’t really the problem. Cathleen London is a primary care physician in Milbridge, a rural town in Maine. She claims the problem isn’t Obamacare itself, but rather, the entire health insurance system and insurance companies are to blame.
Writing for the Portland Press Herald, London explains she is a a primary care physician who is on the front lines every single day, as  her town is very remote, which means it takes 30 to 40 minutes to get to the emergency room, which is why her office operates as an urgent care facility as well as a family medical practice.
It’s takes an ambulance about 20 minutes to get to her clinic and specialist care about 2 hours away, so Dr. London is trained to handle about 90 percent of medical problems.

Dr. London explains the following, which will show you exactly what’s wrong with health care:

One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.
Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.
I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.
I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.
The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).

Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.

Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.
I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.
I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.
My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.
Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.
This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies. Remember lifetime caps? Remember denials for pre-existing conditions? Remember the retroactive cancellation of insurance policies? Returning to that is not an option.
Indeed it is not an option, Dr. London.  If Republicans get their way eventually by repealing Obamacare, it may be where we end up again. If Republicans really get their way, it’ll be even worse than it was before.

What your doctor won’t disclose

What happened when Dr. Leana Wen started a website where doctors could reveal their conflicts of interest? Dr. Wen tells us in a TED Talk.


What your doctor won’t disclose
Leana Wen
TED Talk
Nov 2014

They told me that I'm a traitor to my own profession, that I should be fired, have my medical license taken away, that I should go back to my own country. My email got hacked. In a discussion forum for other doctors, someone took credit for "Twitter-bombing" my account. Now, I didn't know if this was a good or bad thing, but then came the response: "Too bad it wasn't a real bomb."...

Read more (or watch video): What your doctor won’t disclose

Partners, Brigham pay $10M to settle research fraud probe

Partners, Brigham pay $10M to settle research fraud probe

Apr 27, 2017

Max Stendahl 

Boston Business Journal

Partners Healthcare and Brigham and Women’s have agreed to pay $10 million to settle allegations by the federal government that a group of former stem cell researchers at the hospital falsified data to win grant funding from the NIH.

The U.S. Attorney’s Office in Boston announced the settlement, which stems from grant applications submitted by a stem cell research lab run by former Harvard Medical School professor Piero Anversa.

According to the government, Anversa and two other researchers, Annarosa Leri and Jan Kajstura, used “manipulated and falsified information” to obtain funding to study whether stem cells can repair cardiovascular damage. The data was published in a 2012 issue of the journal Circulation, but the study was later withdrawn amid allegations that it had been partially fabricated.

Anversa and Leri sued Brigham in 2014, saying the hospital's investigation into their alleged conduct was flawed and marred by conflicts of interest. A judge dismissed that case in 2015.

On Thursday, prosecutors credited Brigham with voluntarily disclosing the possible fraud to the government, and noted that the scientists are no longer affiliated with the hospital.

“Individuals and institutions that receive research funding from NIH have an obligation to conduct their research honestly and not to alter results to conform with unproven hypotheses,” Acting U.S. Attorney William Weinreb said in a statement. “Medical research fraud not only wastes scarce government resources but also undermines the scientific process and the search for better treatments for serious diseases.”

In a statement, a Brigham spokesperson said the hospital ceased drawing funds implicated in the alleged fraud when the claims came to light, and also closed the lab.

"BWH is committed to ensuring that research conducted at the institution is done under the most rigorous scientific standards, and has made significant enhancements to research integrity compliance protocols as a result of this event," the spokesperson said.