Entries in Health Care (57)


HHS IG: 'Staggering Waste' as Insurers Overcharge Medicare, Patients

Dynamic Graphics/Thinkstock(WASHINGTON) -- A new government investigation finds insurance companies have been overcharging taxpayers and patients by overstating how much they’re paying for drugs. The cost to taxpayers is nearly $2 billion a year.

At issue is Medicare Part D, a program that helps consumers afford prescription drug coverage. Insurers negotiate rebates from drug companies and they are expected to pass savings on to consumers. In fact, the U.S. Department of Health and Human Services Inspector General (HHS IG) found that some insurers failed to report all the rebates they received. They also did not pass savings onto beneficiaries. Insurers received more in rebates than they reported for about 23 million people -- on average about $7 more per beneficiary every month.

“As a result of this underreporting, the total excess rebate payments received by these plans is a staggering $1.98 billion per year, leading to increased drug costs for seniors and billions of American taxpayer dollars wasted,” said Rep. Diana DeGette, D-Colo.

The report said some of inaccuracies could be explained as honest mistakes.

“It is also possible, however,” the report continued, “that some sponsors may deliberately underestimate their rebates to increase profits.”

“When sponsors underestimate rebates in their bids, beneficiary premiums are higher than they otherwise would be and both the government and beneficiaries overpay for the benefit.”

Investigators say Medicare will get back some of the money it overpaid. Benificiaries, however, get nothing back.

Copyright 2011 ABC News Radio


Federal Judge to Clarify Ruling On Health Care Law

Photo Courtesy - Getty Images(WASHINGTON) -- Federal Judge Roger Vinson is poised to issue an order this week clarifying the ruling he made on Jan. 31, 2011, that struck down the entire health care law.

Why does he need to clarify? Because the Obama administration argues it isn’t sure whether Vinson’s ruling was meant to halt the implementation of provisions of the law currently in effect.

Vinson found the individual mandate to be unconstitutional, and he said that the rest of the law could not stand without the mandate, but he declined to impose an injunction which would have immediately blocked the enforcement of the law. Instead he said his ruling was the “functional equivalent of an injunction.”

It’s all a bit of a legal gymnastics because if the administration gets an adverse ruling from Vinson it will immediately appeal to the 11th Circuit.  It’s highly likely that the 11th Circuit would grant a stay.

What parts of the law currently in effect are at issue? The White House says in a blog: “Seniors will pay higher prices for their prescription drugs and small businesses will pay higher taxes because small business tax credits would be eliminated. And the new provisions that prevent insurance companies from denying, capping or limiting your care would be wiped away.”

Meanwhile, the state of Florida, which brought the challenge along with 25 other states, says the administration is playing games: finding a platform to criticize the judge’s ruling when it could have simply immediately asked for a stay.

Copyright 2011 ABC News Radio


Government Releases Health Care Fraudsters Most Wanted List

Image Courtesy - Getty Images(WASHINGTON) -- Health care fraud has cost American taxpayers millions of dollars in recent years, and now the Office of the Inspector General has announced a top-ten list of people most wanted for exploiting the system for their personal gain.

While the OIG says health care fraudsters have cost taxpayers $124 million in total, there are a few notable fugitives who account for a large part of the missing money.

Three brothers working out of Miami allegedly ripped off Medicare for $110 million. One woman took Medi-Cal, the Medicaid program in the state of California, for $17.1 million, authorities say. The OIG says another man billed Medicare for $1.1 million.

Overall OIG says it is tracking about 170 fugitives, but that two of the top ten most wanted have been taken into custody. The organization stressed that it needs all the help it can get from the public, and offers both a phone number and online form to report a fugitive.

The most wanted list is available online at

Copyright 2011 ABC News Radio


Quality of Child Care Varies Greatly by Region

Photo Courtesy - Getty Images(NEW YORK) - A new report has revealed in which states children get the best health care, and in which states they get the worst, reports WebMD.

According to a report card from the Commonwealth Fund, children in the upper Midwest and New England have the best access to affordable health care, prevention, treatment and overall health benefits. Iowa, Massachusetts, Vermont, Maine and New Hampshire made the top five for child health care.
The South and Southwest regions scored the worst with Florida, Texas, Arizona, Mississippi and Nevada making up the bottom five states.

“There are wide gaps between leading and lagging states for oral health problems, obesity, and smoking rates," said Karen Davis, president of the Commonwealth Fund. For example, just three percent of children in Massachusetts were uninsured in 2009, compared to 17 and 18 percent uninsured in Nevada, Florida, and Texas.

Copyright 2011 ABC News Radio


Feds Recovered $4 Billion in Gov't Medical Fraud in 2010 

Photo Courtesy - Getty Images(WASHINGTON) -- Last year was the biggest ever for shutting down efforts to scam federal health care programs. Prosecutors recovered a record-setting $4 billion from hundreds of crooks, big and small.

“The subjects of our investigations include traditional fraudsters, health care providers, corporate executives, hospital systems and administrators and members of organized crime,” said FBI Assistant Director Kevin Perkins at a news conference in Washington Monday.

Federal officials also announced new rules to make it harder for would-be criminals to defraud the government in the future.

“The days when you could just hang out a shingle and start billing the government are over,” said HHS Secretary Kathleen Sebelius.

Among the new rules, which are part of the health care law the House voted last week to repeal, is one that allows Medicare to stop all payments to a provider the moment a credible complaint about fraud has been received. This may terrify executives at some big corporations that sell billions of dollars' worth of drugs, devices and services to the federal government. Major companies like Novartis, AstraZeneca and Allergan, for example, were the subjects of successful fraud investigations last year.

Copyright 2011 ABC News Radio


Half of Americans Have Pre-Existing Health Conditions

Photo Courtesy - Getty Images(WASHINGTON) -- As many as 129 million non-elderly Americans have a pre-existing health condition that puts them at risk of being denied affordable coverage without health care overhaul, according to a government report. The estimate represents nearly half of Americans younger than 65, and 86 percent of people 55 to 64.

Secretary of Health and Human Services Kathleen Sebelius released the report hours before the House of Representatives was set to begin debate Tuesday on a Republican-spearheaded health care repeal bill.

"The timing of the report may be political but that does nothing to diminish its accuracy," said Robert Field, professor of law at the Earle Mack School of Law and professor of health management and policy at the Drexel University School of Public Health in Philadelphia.

What constitutes a pre-existing condition -- one that exists before someone applies for a health insurance policy -- is generally defined by insurers. But ones considered to fall in "high-risk pools" were also counted in the report. So pre-existing conditions ranged from having cancer to having high cholesterol.

Under the Affordable Care Act -- part of the health care legislation passed by the last Congress and signed into law by President Obama on March 23, 2010 -- insurers can no longer base eligibility, benefits or premiums on a person's health status, starting in 2014.

Copyright 2011 ABC News Radio


Medical Insurance Changes for 2011

Photo Courtesy - Getty Images(WASHINGTON) -- Under President Obama's Affordable Care Act, which was signed into law on March 23, 2010, insurers must offer parents the option of keeping their adult children covered under their medical plan until age 26. This mandate went into effect for most medical insurance plans whose benefit year begins Jan. 1, 2011.

Most health insurance plans previously dropped children from parental insurance plans once they turned 19 or graduated college. This controversial insurance modification is seen by many Americans as an extension of childhood for adults in their 20s, while for others, the measure is necessary to end the insurance gap that affects many young people.

A 2008 survey conducted by the National Institutes of Health showed that about 30 percent of adults between the ages of 20 and 29 do not have health insurance, a circumstance largely brought on by large numbers of young adults taking nontraditional, temporary or low-paying jobs that do not come with conventional employee benefits such as health insurance. That makes this age group the largest without health insurance.

While coverage for adult children depends entirely on their parents' insurance policy (for example, vision and dental care may not be included as eligible benefits), adult children -- including those married and the financially independent -- can now be included on their parents' plans.

Under the federally mandated new law, all health care plans are required to provide coverage to children under the age of 19, regardless of pre-existing health conditions, but similar coverage may not be extended to those older than 19. Additionally, bringing in an adult child will incur additional costs, the extent of which depends on the insurance provider and the amount of dependents listed on a plan. However, a qualified young adult must be offered coverage at the same cost as any other dependent on a parent's existing plan.

No special action is required by parents or their insurance dependents. Their dependents only need to enroll during the plan's open enrollment period, which, for most plans, ends on the first day of the new benefit year.

Copyright 2011 ABC News Radio


New Year, New Health Care Provisions: What You Can Expect

Photo Courtesy - Getty Images(WASHINGTON) -- The new year brings new changes in the U.S. health care system.

Although most of the new provisions that will roll out next week as part of the Affordable Care Act apply mainly to insurers, they will have a direct impact on consumers too.

Here's a look at some of the changes Americans can expect starting Jan. 1, 2011.

One provision that triggered particular controversy earlier this year was end-of-life counseling, which the federal government will pay for starting Jan. 1.

The White House points out that the option will now be covered as part of the new annual wellness visit created by the Affordable Care Act.

The provision has revived discussion of "death panels" -- a term first coined by Betsy McCaughey, a Republican health policy expert and the former lieutenant governor of New York -- which was widely used by former Alaska Gov. Sarah Palin. The provision could be one of the targets for repeal or defunding in the new Congress.

Pharmaceutical manufacturers will have to provide a 50 percent discount on brand-name prescription drugs to older Americans who fall into the "doughnut hole," the out-of-pocket expenses Medicare recipients have to pay once their prescription drug costs reach $2,830.

The "doughnut hole" will eventually be phased out so that enrollees in the Medicare Part D drug coverage program will be responsible only for 25 percent of their prescription drug costs by 2020.

In 2010, elderly Americans who fell into the gap received a $250 rebate check.

There will be a 10 percent Medicare bonus payment for primary care services and a 10 percent Medicare bonus payment to some surgeons in specialties with fewer doctors.

That component of the health care bill lasts until Dec. 31, 2015.

The new law eliminates any cost sharing Medicare beneficiaries need to pay for preventive care and waives the deductible for colorectal cancer screening tests.

A 15-member, independent advisory board will be established to study how to reduce Medicare spending if it exceeds targeted growth rates.

Under the new law, insurance companies serving the large group market will have to devote 85 percent of every dollar to patient care and improving quality of care, instead of such expenses as overhead costs, executive salaries or dividends for shareholders. For those serving small business and individuals, that has to amount to 80 percent of every dollar.

If insurance companies fail to meet these standards, they will have to provide rebates to consumers.

The medical loss ratio -- the ratio of medical expenses to administrative spending -- came under fire last year when some companies, such as McDonald's, reportedly threatened to drop limited coverage plans because of the new standards.

A new program will go into effect that will provide matching federal funds for long-term care services under Medicaid. The federal government will also provide funds for home health care and attending services for people with disabilities.

The Medicaid expansion under the new health care law has met with resistance from many state governments that say it puts additional burdens on them at a time when they're struggling with budget deficits.

Copyright 2010 ABC News Radio


Leapfrog Releases List of Top US Hospitals

Photo Courtesy -- Getty Images(WASHINGTON) – The Leapfrog Group on Wednesday released their annual list of the nation’s top hospitals.

Of the nation’s estimated 5,000 hospitals, 1,200 reported performance to Leapfrog. Among the best performing hospitals were 16 that belong to Kaiser Permanente, one of the nation’s largest not-for-profit health plans.

A surprise is the exclusion of New York City’s Columbia Presbyterian, which routinely makes the U.S. News list of the nation's top 10 hospitals.

The survey focused on “four critical areas of patient safety,” including the use of computer physician order entry to prevent medication errors, standards for high-risk procedures, protocols and policies to reduce medical errors and adequate staffing.
Copyright 2010 ABC News Radio


States Battle with Federal Government on Health Care

Photo Courtesy - Getty Images(WASHINGTON) -- At a time when Medicaid enrollment is on a steady rise and the economy remains weak, health care has also unearthed old tensions between states and the federal government that lie at the heart of the health care debate.

The expansion of the Medicaid program under the new health care law, and additional measures like the requirement that every American must carry health insurance and states must set up health insurance exchanges -- where the uninsured would be able to shop for coverage and compare rates -- have aroused rebellion from states.

Twenty states have filed a joint lawsuit against the Department of Health and Human Services, challenging the constitutionality of the provision that requires all Americans to purchase health insurance by 2014.

The feud over health care between states and Washington is not new. It has existed since the program was created in 1965, but the current partisan climate in which political jockeying is on the rise just further exacerbates that tension.

"This is not exactly a new issue when states feel fiscally pressed," said Gail Wilensky, an economist and a senior fellow at Project Hope, an international health education foundation.

Medicaid has been particularly hard hit by the budget crisis and the weak economy. Spending on Medicaid rose an average of 8.8 percent this year, the highest rate of growth in eight years, according to the Kaiser Family Foundation. The federal stimulus program gave some relief to states, providing roughly $87 billion in October 2008.

Under the new health care law, the federal government will provide funding to expand Medicaid to Americans whose incomes are at or below 133 percent of the federal poverty line.

But that has done little to appease states, many of which say the new law will increase their costs in the long-term even though it expands coverage to more citizens.

The blame game is likely to continue in an issue that is growing increasingly complex, experts say.

"There's not an easy villain," said William Roper, dean of the school of public health at University of North Carolina, Chapel Hill. "We as Americans want people to be covered by health insurance and get health services that they need, but we have a much greater appetite for public services than we have an appetite for the taxes that pay for them and that has produced over years -- and more recently over the last few years -- a gigantic budget deficit."

"The greater challenge for states right now is how can we give people everything and stay solvent and do what the federal government wants," said Sreedhar Potarazu, an ophthalmologist and chief executive of Vital Spring Technologies. "States are on the verge of going over the cliff and health care is the last straw."

Copyright 2010 ABC News Radio

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