MLC Leader On Medicare Advantage: ‘We’ve Got The Contract Written Up’ - Work-Bites

 A good comprehensive article on the overall situation. Note the comment from the guy from New Jersey, where teachers have been moved from Medicare to MedAdv -- my friend called about one of his friends who was not aware of the change. Her husband has cancer and has paid very little for treatment and then suddenly started getting enormous bills from the hospital where they said she is now on MedAdv and they don't take that insurance. So claims by these officials should be taken with a big grain of salt. Another issue I read about is that our fearless negotiators are trying to get the insurers to cut down on the number or prior authorizations - which means there is resistance.

 

 

 https://www.work-bites.com/view-all/mlc-leader-on-medicare-advantage-weve-got-the-contract-written-up

MLC Leader On Medicare Advantage: ‘We’ve Got The Contract Written Up’

LatestTri-State News

Feb 4

Mayor Eric Adams’ administration and the heads of the MLC continue to push Medicare Advantage against the objections of many retired and active municipal workers. Photo By Joe Maniscalco

By Bob Hennelly

The deadline for the City Council to change its Administrative code that covers how the city provides healthcare insurance for its active-duty workforce and retirees came and went last month without the Council opting to act after a marathon Jan. 9 public hearing where scores of city retirees blasted the proposal.  

Meanwhile, the Adams administration and the Municipal Labor Committee are closing in on a deal with Aetna to provide a Medicare Advantage plan for the city’s 250,000 retirees, according to Harry Nespoli, chairman of the Municipal Labor Committee, and president of Teamsters Local 831, which represents the Department of Sanitation’s rank and file workforce.

“We are still working on it,” Nespoli told Work-Bites. “We got the contract written up and our official people are all looking it over right now — we are just going to continue moving towards it.” Nespoli added that the MLC had made progress on getting Aetna to further reduce the number of procedures that would require a pre-authorization.

“We have eliminated a lot of the pre-authorizations already and we want to continue doing that because that is the biggest gripe with Emblem [the current provider], and from what we are hearing these pre-authorizations take too much time to get the o.k. for something,” Nespoli said. “If you look throughout the country, Medicare Advantage is the way it’s going for a large group of people. It’s just that you have to make sure that you have the right contract, and you justify the needs of your members---who have had good medical coverage and which we don ‘t want see cheapened now.”

An Adams administration source described the negotiations as ongoing, and a United Federation of Teachers source confirmed an earlier Crain’s New York report that UFT was “requesting an independent entity to conduct pre-authorization reviews for medical procedures in addition to Aetna’s reviews.”

The MLC’s controversial embrace of Medicare Advantage is the outgrowth of deals it cut with the de Blasio administration to find billions of dollars in healthcare costs savings as unions settled well over 100 labor contracts that Mayor Bloomberg had left unsettled for years. And multiple union sources confirm Mayor Adams finds himself in a similar fix with union contracts lapsed and the understanding that no progress can be made on any of them without a resolution of the healthcare question.

FRAUD FOR PROFIT?

Medicare Advantage Fraud: New Medicare Rule Aims to Take Back $4.7 Billion From Insurers - NYT

 I'm sharing articles on MedAdv fraud to give us weapons to use in fighting back when our union leaders claim MedAdv is just medicare part c.

MedAdv fraud drains billions from Medicare and helps undermine it. This also addresses calls to cut Medicare. Republicans may point to this fraud as a good reason. But the counter is that by pulling back these billions from insurance companies that is saving money. Last week we heard the lobbying efforts were successful in keeping them from going after the money. But this is only fraud from 2018 - and there was some efforts by the Trump admin to address this issue. We know both parties are subject to the industry lobbying.  There are calls to get money back from 2011 but that is not going to happen.

Norm

New Medicare Rule Aims to Take Back $4.7 Billion From Insurers

The government plans to aggressively audit Medicare Advantage plans for overbilling but may face lawsuits.

 

https://www.nytimes.com/2023/01/30/upshot/medicare-overbilling-biden-rule.html

By Reed Abelson and Margot Sanger-Katz

Jan. 30, 2023

4 min read

The Biden administration announced a rule Monday cracking down on Medicare private plans that have overcharged the federal government. The rule calls for a more aggressive approach to how plans are audited in the Medicare Advantage program, which enrolls nearly half of all Medicare beneficiaries.

The administration said it expects to collect as much as $4.7 billion over a decade from its heightened oversight. The rule strengthens the ability of the government to audit plans and recover the overpayments. It is the government’s strongest action against the practices in more than a decade.

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

Oct. 8, 2022

At a news conference announcing the change, Xavier Becerra, the health and human services secretary, acknowledged that Medicare had been criticized for not taking a hard enough stand against the plans’ pattern of overcharging. “Today, we are taking some long-overdue steps to move us in the direction of accountability,” he said.

As Medicare Advantage has become increasingly popular with older Americans, he said the agency needed to make sure it was properly overseeing the private plans. “We want to encourage correct reporting across the program,” he said.

Health insurers had lobbied heavily against the policies in the rule, which relate to a system of risk adjustment, and are likely to bring legal action against the government. Mr. Becerra said he could not speculate on any potential litigation, but he emphasized he thought the new rule was ready “for prime time.”

Insurers were upset by the rule. “This rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized,” said Matt Eyles, president of AHIP, a large insurer trade group, in a statement.

Health Care in the United States

• Medicare: The Biden administration announced a rule targeting Medicare private plans that overcharge the federal government. The change strengthens the ability to audit plans and recover overpayments.
  

 

Evidence from government audits, fraud lawsuits and academic analysis has shown that many plans have been systematically overcharging the federal government for years by exaggerating the health problems of their customers to collect extra payments. But the Centers for Medicare and Medicaid Services, which regulates the plans, has been reluctant to tackle the overcharging in the face of industry opposition, technical complexity and the plans’ popularity.

Under current rules, regulators have been closely reviewing a small subset of patient medical records to compare them with billing codes sent to the federal government. Under the new policy, the error rate found in the sample will be extrapolated across all the records in the plans since 2018, a change that would substantially increase the magnitude of possible repayments. Officials said plans owe the government $479 million in overpayments from 2018 alone.

 

The extrapolation approach was first proposed in 2018 by the Trump administration. Monday’s regulation makes the new audit system final. But the original proposal would not have made the payments retroactive. “It’s appropriate to have extrapolation going forward,” said Seema Verma, who was the C.M.S. administrator when the rule was first proposed in 2018. But she said the retroactive nature of the rule was “extremely unfair and problematic.”

“They’re likely to get sued,” she said

But some industry critics had been calling for Medicare to go even further, applying the broader penalties as far back as 2011, when the audits began.

“At least we’re on the right track now,” said Ted Doolittle, a former senior Medicare official, who said he was disappointed the agency had gone back only to 2018. But he commended federal officials for their decision to extrapolate from the results of the audits.

The rule also does not include a formula adjustment that insurers had asked for, which would have reduced the penalty amounts in some cases. Medicare officials said the change was not necessary.

Medicare Advantage plans have become popular and are expected to cover the majority of Medicare beneficiaries by the end of this year. They often offer customers lower premiums than the government Medicare plan, and they cover additional benefits like dental care. Plans have warned that regulations that reduce payments to the plans could erode their ability to offer such extra benefits.

The plans have become a major profit center for insurance companies. They earn more gross profit on Medicare plans than other types of insurance, according to a study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser.

In the press call, Dara Corrigan, the C.M.S. director of the center for program integrity, emphasized that even the billions in estimated recoveries from the plans were small compared with the scope of the program. She said the estimated $4.7 billion in recovered overpayments represented one fifth of one percent of federal payments to the plans over the period.

The audits will focus on extra payments the plans receive when they care for patients who have serious health conditions. The extra payments are meant to compensate the companies for the additional costs associated with treating sicker patients, as part of risk adjustment. But identifying additional diagnoses in order to collect the extra payments has become a major strategic goal of industry players, which use software, home health visits and other measures to maximize the number of diagnoses for each patient, evidence has shown.

Three of the five largest insurers in the industry have been accused of fraud by the Justice Department for inflating diagnoses.

Medicare has come under particular criticism for its handling of audits. The audit details were secret until Kaiser Health News was able to review summaries of the examinations from 2011 to 2013 after it settled a three-year Freedom of Information Act lawsuit against the agency last fall. The reporting estimated there were millions of dollars in overpayments that would mean billions of dollars in penalties if they were extrapolated broadly.

Insurance companies have long defended the current system of risk adjustment as essential to making sure health plans do not discriminate against older adults with potentially expensive illnesses. “Risk adjustment is critical in providing broad and equitable access to care for seniors,” said Tim Noel, UnitedHealthcare’s C.E.O. for Medicare and retirement, before the rule was announced.

AHIP warned in a 2019 letter outlining its objections that “seniors and hardworking taxpayers might see higher costs, reduced benefits, and fewer” Medicare Advantage plan options.

The group went on to question whether Medicare officials had the legal authority to extrapolate widespread errors from a limited audit and collect overpayments from mistakes made years before.

The rule was released Monday after the closing of markets. Many of the major insurers are public companies, and investors have been awaiting its release.

“The managed care companies will challenge the rule but, in any event, it’s only a slight negative for the stocks,” said Les Funtleyder, a health care portfolio manager at E Squared, which holds shares of UnitedHealth Group, in an email. “It could have been worse.”

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook 

 

 

 

 

jjj

‘Cancel This Failed Experiment’: Physicians Tell Biden HHS To End Medicare Privatization Pilot

 

‘Cancel This Failed Experiment’: Physicians Tell Biden HHS To End Medicare Privatization Pilot

Jake Johnson
January 19, 2023
Common Dreams

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The Medicare privatization program "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries," said Physicians for a National Health Program. 

 

A national physician group this week called for the complete termination of a Medicare privatization scheme that the Biden White House inherited from the Trump administration and later rebranded—while keeping intact its most dangerous components.

Now known as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model, the experiment inserts a for-profit entity between traditional Medicare beneficiaries and healthcare providers. The federal government pays the ACO REACH middlemen to cover patients' care while allowing them to pocket a significant chunk of the fee as profit.

The rebranded pilot program, which was launched without congressional approval and is set to run through at least 2026, officially began this month, and progressive healthcare advocates fear the experiment could be allowed to engulf traditional Medicare.

In a Tuesday letter to Health and Human Services Secretary Xavier Becerra and Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure, Physicians for a National Health Program (PNHP) argued that ACO REACH "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries."

The group, which advocates for a single-payer healthcare system, voiced alarm over the Biden administration's decision to let companies with records of fraud and other abuses take part in the ACO REACH pilot, which automatically assigns traditional Medicare patients to private entities without their consent.

CMS said in a press release Tuesday that "the ACO REACH Model has 132 ACOs with 131,772 healthcare providers and organizations providing care to an estimated 2.1 million beneficiaries" for 2023.

"As we have stated, PNHP believes that the REACH program threatens the integrity of traditional Medicare and should be permanently ended," Dr. Philip Verhoef, the physician group's president, wrote in the new letter. "Whether or not one agrees with this statement, we should all be able to agree that companies found to have violated the rules have no place managing the care of our Medicare beneficiaries."

Among the concerning examples PNHP cited was Clover Health, which has operated so-called Direct Contracting Entities (DCEs)—the name of private middlemen under the Trump-era version of the Medicare pilot—in more than a dozen states, including Arizona, Florida, Georgia, and New York.

PNHP noted that in 2016, CMS fined Clover—a large Medicare Advantage provider—for "using 'marketing and advertising materials that contained inaccurate statements' about coverage for out-of-network providers, after a high volume of complaints from patients who were denied coverage by its MA plan. Clover had failed to correct the materials after repeated requests by CMS."

Humana, another large insurer with its teeth in the Medicare privatization pilot, "improperly collected almost $200 million from Medicare by overstating the sickness of patients," PNHP observed, citing a recent federal audit.

"It appears that in its selection process [for ACO REACH], CMS did not prevent the inclusion of companies with histories of such behavior," Verhoef wrote. "Given these findings, we are concerned that CMS is inappropriately allowing these DCEs to continue unimpeded into ACO REACH in 2023."

While the Medicare pilot garnered little attention from lawmakers when the Trump administration first launched it during its final months in power, progressive members of Congress have recently ramped up scrutiny of the program.

Last month, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) led a group of lawmakers in warning that ACO REACH "provides an opportunity for healthcare insurers with a history of defrauding and abusing Medicare and ripping off taxpayers to further encroach on the Medicare system."

"We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare," the lawmakers wrote, echoing PNHP's concerns. "The continued participation of corporate actors with a history of fraud and abuse threatens the integrity of the program."

[Jake Johnson is a staff writer for Common Dreams.]

Licensed under Creative Commons (CC BY-NC-ND 3.0). Feel free to republish and share widely 

Medicare Advantage Is a National Scandal - How Thick Could New York City’s Information Bubble Be? Work Bites

 

 https://www.work-bites.com/view-all/1n72juz2psj2e6v48d80bgwyati58c?fbclid=IwAR1yo5uAUf0jpWL723sE2H3PfUvGn-rsymJaC3lr0pWhrF2hwPdFX1p5x5c

Medicare Advantage Is a National Scandal - How Thick Could New York City’s Information Bubble Be?

 

By Joe Maniscalco

Collusion.

That’s what the campaign by New York City Mayor Eric Adams and the heads of the Municipal Labor Committee [MLC] to push municipal retirees into a privatized for-profit Medicare Advantage healthcare program looks like to the many thousands who’ve spent more than a year trying to stop the plan.

What else can a rational human being conclude other than collusion against municipal retirees?

Medicare Advantage is one of the filthiest scandals in America today with lawmakers in Congress calling for the program’s nationwide abolition. And yet, the heads of the biggest city in the country are running around insisting Medicare Advantage is a good deal for retirees.

Really?

How thick would that bubble have to be to keep all that information out?

Work-Bites has already reported on some of the mounting evidence against privatized, for-profit Medicare Advantage plans and the delays, denials and deaths that come with them.

Here’s a little recap: earlier this month, retired Delaware State Senator Karen Peterson told us how “your healthcare can really go off the rails” with Medicare Advantage.

Nevertheless, the powerbrokers in Peterson’s state, as here in NYC, tried to sell municipal retirees on Medicare Advantage, insisting it was “just as good” as what they already had — “only better.”

Turns out, the Medicare Advantage contract Delaware signed with a private healthcare insurance company in September, actually contained 2,030 pre-authorizations — 340 pre-authorizations for medications — and 1,690 pre-authorizations for procedures.

Few things concern dedicated municipal retirees more than suddenly not being able to see their doctor.

A recently-released report from the U.S. Senate Committee on Finance critical of Medicare Advantage chicanery found instances of “provider network confusion” across 10 states where the beneficiary was “switched into a new plan and was unaware that their current doctors were not covered under their new plan’s network until they began to use the new plan.”

Gale Brewer, former Manhattan Borough President and current City Council Member representing the Upper West Side, doesn’t seem to have any problem piercing any sort of Medicare Advantage information bubble.

“The city has offered various Medicare Advantage plans for years,” Brewer said in a statement this week, “but few retirees choose them because they are demonstrably worse than Senior Care.”

She goes on to say, “Medicare advantage plans give private insurance companies the power to overrule primary care physicians — and to say which procedures will be permitted,” she added. “Many retirees have health care issues and work very hard to stay healthy. Keeping their current insurance plan, called Senior Care, is critical in retaining access to their doctors and ensuring continuity of care.”

Gale Brewer gets it.

WHY AREN’T THEY TALKING WITH RETIREES?

That awareness has prompted Brewer to urge all parties involved to “sit down together and work this out.”

Marianne Pizzitola, president of the NYC Organization of Public Service Retirees and Fire Department EMS Retirees Association, has spent months calling for a sit-down with MLC heads Michael Mulgrew, Harry Garrido and Harry Nespoli.

Instead of taking her up on the offer, however, the trio, along wih Mayor Eric Adams — the former Medicare Advantage critic who used to call the program a “bait and switch” — have been pushing pell-mell to privatize the healthcare for tens of thousands of retired trade unionists — raging in the courts, issuing ultimatums, leaning on New York City Council members to tear up part of the City Administrative Code and implementing extra health costs.

Again, all at the precise moment Medicare Advantage plans are being exposed as predatory money grabs and raked across the coals from coast-to-coast.

Brewer correctly characterizes for-hire arbitrator Martin Scheinman’s December 15, filing in favor of the Medicare Advantage switcheroo a “non-binding report.”

Pizzitola is more blunt, calling it “paid propaganda.”

”The December 15th Scheinman report is not a “ruling”, it’s an opinion,” Pizzitola said in a statement released this week. “It’s paid propaganda and they’re hoping the city council falls for it. It is not a decision, it is not a ruling, it is not an award…and yet everyone fell for the biggest play in history…a paid opinion piece!”

Municipal retiree groups have already identified at least $300 million in savings to the City of New York — and none of it necessitates pushing them into a disastrous for-profit Medicare Advantage plan that progressive lawmakers in D.C. say ought to be abolished.

“OMB knows about some of these savings options, and has not implemented them,” Pizzitola says. “Nor have they informed the city council they exist. OMB was unaware of others we suggested in a recent meeting! Which is worse? And yet they told the Mayor’s office there is only one path forward! How can the mayor or the council make a decision if they are not being properly informed by OMB?”

Those leading the charge for Medicare Advantage are some of the most powerful people in the City of New York today. Elderly Municipal retirees are among the weakest and most vulnerable. But they are all hard-working trade unionists who’ve spent their entire working careers in education, the Fire Department, building trades, law enforcement — you name it. Corporate-owned, anti-labor media outlets in this town, as they did in Delaware, are trying to dismiss them all as a small group of crotchety old cranks. We should all remember that and consume our media accordingly.

New York City municipal retirees certainly remember the 2014 pact between former Mayor Bill de Blasio’s administration and UFT President Michael Mulgrew — the faustian deal that allowed $1.3 billion from the city’s Health Stabilization Fund to be used to cover needed raises following a decade of austerity under billionaire Mayor Mike Bloomberg.

They’ve connected all the dots and refuse to be steamrolled by anyone. They simply can’t afford to pretend to live in a Medicare Advantage information bubble. And neither can any of the “retirees in training” following right after them.

Thom Hartmann: Why Is the For-Profit Healthcare Industry Like a Blood-Sucking Tick? Via Ravitch

 Surprise, surprise!

Thom Hartmann: Why Is the For-Profit Healthcare Industry Like a Blood-Sucking Tick?

dianeravitch Jan 20

Thom Hartmann provides a brief history of the power of the for-profit healthcare industry, which has successfully blocked a national Medicare-for-All system. Please open the link and read it all. The industry’s current push is to get people transferred from Medicare to for-profit Medicare Advantage plans. Under Medicare, seniors can choose their own doctors and do not have to seek permission for costly procedures. under Medicare Advantages, patients may see only in-network doctors and may be denied permission for treatment. That’s where the profit is: denying treatment. About half of all seniors are on a Medicare Advantage plan, because they were wooed by prescription drug coverage or a free gym membership.

Hartmann begins:

Republicans have taken control of the House of Representatives, and already have their sights set on forcing major cuts to “entitlements” like Social Security, Medicare, and Medicaid.

One of the promises McCarthy made to become speaker was to force a vote on dialing back 2023/2024 spending back to 2021 levels — and there’s been a 7% inflation increase in costs/expenses since then. In other words, they want massive cuts.

His Republican colleagues have already outlined the starting point for their demands, as reportedby Yahoo News:

“The Republican Study Committee proposed a budget for fiscal 2023 that would gradually increase the eligibility ages for Social Security and Medicare, and change the Social Security benefit formula for people 54 and younger…”

In that, they’re going to have a hell of a fight on their hands, as Senator Bernie Sanders is taking over leadership of the Senate Health Committee, which oversees Medicare and Medicaid. He’s already promising “a lot of subpoenas” will be arriving at the offices of healthcare and big pharma CEOs.

Most Americans have no idea that the United States is quite literally the only country in the developed world that doesn’t define healthcare as an absolute right for all of its citizens.

That’s it. We’re the only one left. Were the only country in the developed world where somebody getting sick can leave a family bankrupt, destitute, and homeless.

A half-million American families are wiped out every year so completely that they must lose everything and declare bankruptcy just because somebody got sick. The number of health-expense-related bankruptcies in all the other developed countries in the world combined is zero.

Yet the United States spends more on “healthcare” than any other country in the world: about 17% of GDP.

Switzerland, Germany, France, Sweden and Japan all average around 11%, and Canada, Denmark, Belgium, Austria, Norway, Netherlands, United Kingdom, New Zealand and Australia all come in between 9.3% and 10.5%.

Health insurance premiums right now make up about 22% of all taxable payroll (and don’t even cover all working people), whereas Medicare For All would run an estimated 10% and would cover every man, woman, and child in America.

How and why are Americans being played for such suckers?

We are literally the only developed country in the world with an entire multi-billion-dollar for-profit industry devoted to parasitically extracting money from us to then turn over to healthcare providers on our behalf. The for-profit health insurance industry has attached itself to us like a giant, bloodsucking tick.

And it’s not like we haven’t tried to remove that parasite.

Presidents Theodore Roosevelt, Franklin Roosevelt, Harry Truman, Jack Kennedy and Lyndon Johnson all proposed and tried to bring a national healthcare system to the United States.

Please open the link and read the rest of this important post.

Diane Ravitch's blog