HHS CLAIMS AFFORDABLE CARE ACT SAVES CONSUMERS $1.2 BILLION

FROM:  U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Health care law saves consumers $1.2 billion nationwide

A new report released today by the Department of Health and Human Services (HHS) shows that 6.8 million consumers saved an estimated $1.2 billion on health insurance premiums in 2012, due to the “rate review” provision of the Affordable Care Act, which brought unprecedented accountability to slow the growth of health insurance premiums.  The Affordable Care Act, along with state efforts, continues to bring scrutiny to proposed health insurance rate increases and is saving consumers real money as a result.

“Thanks to the health care law, we are seeing that holding insurance companies accountable is leading to increased competition and saving billions of dollars for consumers across the country,” said Kathleen Sebelius, Secretary of HHS. “This type of competition and transparency will continue in the Health Insurance Marketplace, or Exchanges, where Americans will be able to shop for and compare plans side-by-side to find the one that fits their needs and budget.”

Beginning on Sept. 1, 2011, the federal rate review rules under the health care law were implemented. These rules ensure that, in every state, insurance companies are required to submit for review and justify any proposed health insurance premium increase of 10 percent or more.

To assist states in this effort, the Affordable Care Act provides states with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.  Forty-six states, the District of Columbia, and five territories have been awarded rate review grant funds to make the rate review process stronger and more transparent.

These provisions have put an end to the days when insurance companies could raise health insurance premiums by double digit percentages with little oversight.  Because of rate review, the report released today shows that consumers have saved approximately $1.2 billion over the past year in the individual and small group markets.

This initiative is one of many in the health care law aimed at saving money for consumers and specifically works in conjunction with the 80/20 rule, which requires insurance companies to spend at least 80 percent of premiums on health care or provide rebates to their customers, instead of overhead, administrative expenses. Thanks to the 80/20 rule, last year 77.8 million consumers saved an estimated $3.4 billion up front on their premiums as insurance companies operated more efficiently.  Insurance companies that did not meet the 80/20 rule provided nearly 8.5 million Americans with $500 million in rebates.

MEDICAL COMPANY OFFICER AND A PHYSICIAN SENTENCED FOR ROLES IN $1.5 MILLION MEDICARE FRAUD

FROM:  U.S. JUSTICE DEPARTMENT 
Tuesday, September 10, 2013
Medical Supply Company Officer and Southern California Physician Sentenced for $1.5 Million Medicare Fraud

A former officer of Fendih Medical Supply Inc. was sentenced to serve 51 months in prison yesterday in Los Angeles for his role in a fraud scheme that resulted in $1.5 million in fraudulent claims to Medicare.  In addition, a physician was sentenced to 27 months in prison for his role in the scheme.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney André Birotte Jr. of the Central District of California, Special Agent in Charge Glenn R. Ferry of the Los Angeles Region of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) and Assistant Director in Charge Bill L. Lewis of the FBI’s Los Angeles Field Office made the announcement.

Godwin Onyeabor, 49, of San Bernandino, Calif., was sentenced on Sept. 9, 2013, by U.S. District Judge Manuel L. Real in the Central District of California to 51 months in prison.  In addition to his prison term, Onyeabor was sentenced to three years of supervised release. Restitution will be determined at a later date.  Dr. Sri J. Wijegunaratne, 58, of Anaheim, Calif., was sentenced to 27 months in prison by Judge Real.  In addition to his prison term, Wijegunaratne was sentenced to three years of supervised release and ordered to pay restitution in the amount of $87,846.

On April 24, 2013, a jury in Los Angeles federal court found Wijegunaratne, Onyeabor and Heidi Morishita, 48, guilty of one count of conspiracy to pay and receive kickbacks.  In addition, Wijegunaratne and Onyeabor were found guilty of conspiracy to commit health care fraud.  Wijegunaratne was found guilty of seven counts of health care fraud, and Onyeabor was found guilty of eleven counts of health care fraud.

During trial, the evidence showed that Onyeabor, as the former officer of a durable medical equipment (DME) supply company, fraudulently billed more than $1 million to Medicare for DME that was either never provided to its Medicare beneficiaries or was not medically necessary.  Wijegunaratne provided Onyeabor and others with medically unnecessary power wheelchair prescriptions, and both Wijegunaratne and Morishita sold power wheelchair prescriptions to Onyeabor and others.  

The evidence showed that Onyeabor and others paid Wijegunaratne and Morishita cash kickbacks for fraudulent prescriptions for DME, and Onyeabor and others used these prescriptions to bill Medicare for the power wheelchairs and other DME.  Several Medicare beneficiaries testified that they were lured to medical clinics with the promise of free items such as vitamins and juice, only to receive power wheelchairs which they did not need and did not want, and were unsuccessful in their attempts to reject delivery of the power wheelchairs from Onyeabor’s supply company.

As a result of this fraud scheme, Onyeabor, Wijegunaratne and others submitted and caused the submission of approximately $1.5 million in false and fraudulent claims to Medicare and received almost $1 million on those claims.

Morishita’s sentencing is scheduled for Sept. 30, 2013.

The case is being investigated by the FBI and the Los Angeles Region of the HHS-Office of Inspector General (HHS-OIG) and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California.  The case is being prosecuted by Assistant Chief Benton Curtis, Trial Attorneys Fred Medick and Alexander Porter of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion.  In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

HEALTH CARE COMPANY OWNERS SENTENCED FOR ROLES IN $17.1 MILLION FRAUD

FROM:  U.S. JUSTICE DEPARTMENT 
 Thursday, August 15, 2013
Operators of Louisiana Home Health Company Sentenced for $17.1 Million Health Care Fraud Scheme

The owner of South Louisiana Home Health Care Inc. and the director of nursing for the Louisiana home health agency were sentenced today for their roles in a Medicare fraud scheme involving the payment of kickbacks and the falsification of documents.

Acting Assistant Attorney General Mythili Raman of the Criminal Division; Acting U.S. Attorney Walt Green of the Middle District of Louisiana; Special Agent in Charge Mike Fields of the Dallas Region of the HHS Office of the Inspector General (HHS-OIG); Special Agent in Charge Michael Anderson of the FBI’s New Orleans Division; and Louisiana State Attorney General James Buddy Caldwell made the announcement.

Louis T. Age Jr., 64, owned and operated South Louisiana Home Health Care and operated this company along with his former wife, Verna Age, 60, who served as the company’s director of nursing. Louis Age and Verna Age, both of Slidell, La., were sentenced today by U.S. District Judge James J. Brady of the Middle District of Louisiana to 180 months and 60 months in prison, respectively, and ordered to forfeit $9.2 million and pay $17.1 in restitution.

After a jury trial in March 2013, Louis Age and Verna Age each were convicted of one count of conspiracy to commit health care fraud, and Louis Age also was convicted of one count of conspiracy to defraud the United States and to pay or receive illegal health care kickbacks.  Verna Age previously was convicted of one count of conspiracy to defraud the United States and to pay or receive illegal health care kickbacks after a jury trial in October 2012.

According to evidence presented at trial, Louis Age and Verna Age paid kickbacks to patient recruiters to obtain Medicare beneficiary information.  Nurses, including registered nurse Verna Age, then falsified qualification documents to make it appear that these beneficiaries qualified for home health services.  The evidence also showed that Louis Age hired and paid kickbacks to medical doctors to sign fraudulent referrals and certifications for home health services that were not medically necessary.  Louis Age and Verna Age then used the Medicare beneficiary information and false documents to bill Medicare for the medically unnecessary home health services.  From 2005 through 2011, Medicare paid South Louisiana Home Health Care approximately $17.1 million based on these fraudulent home health care claims.
 
This case was investigated by the FBI, HHS-OIG and Medicaid Fraud Control Unit of the Louisiana State Attorney General’s Office and was brought as part of the Medicare Fraud Strike Force, under supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Middle District of Louisiana. The case was prosecuted by Trial Attorneys David M. Maria and Abigail B. Taylor of the Fraud Section, with assistance from Trial Attorney Arunabha Bhoumik.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,500 defendants who have collectively billed the Medicare program for more than $5 billion.  In addition, HHS’s Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

HHS TOUTS "SECURE HEALTH DATA" AS AN IMPROVEMENT IN CARE

FROM: U.S. HEALTH AND HUMAN SERVICES

Secure health data helping patients, doctors improve care and health

Health and Human Services (HHS) Secretary Kathleen Sebelius today announced the release of new data and new opportunities for researchers and developers at the beginning of Health Datapalooza IV. This is the fourth annual national conference on health data transparency, which brings together government, non-profit, and private sector organizations to look at the potential for open data from HHS and other sources to help improve health and health care.

The Centers for Medicare & Medicaid Services (CMS) today released new data – including county-level data on Medicare spending and utilization for the first time, as well as selected data on hospital outpatient charges. In addition, the HHS Office of the National Coordinator for Health Information Technology (ONC) released additional information on the adoption of specific electronic health record (EHR) systems, as well as the winners of new opportunities for building innovative tools that build off health data.

"A more data driven and transparent health care marketplace can help consumers and their families make important decisions about their care," said Secretary Sebelius. "The administration is committed to making the health system more transparent and harnessing data to empower consumers."

Today HHS released data and tools that will help researchers and consumers take advantage of health information:
Building on the release last month of the average charges for the 100 most common inpatient procedures, CMS today released selected hospital outpatient data that includes estimates for average charges for 30 types of hospital outpatient procedures from hospitals across the country, such as clinic visits, echocardiograms, and endoscopies.
CMS today released new data sets for the first time at the county level: one on Medicare spending and utilization, and another on Medicare beneficiaries with chronic conditions. Both data sets will enable researchers, data innovators and the public to better understand Medicare spending and service use, spurring innovation and increasing transparency, while protecting the privacy of beneficiaries. The data will also be available through an interactive state level dashboard based on the spending information, allowing users of any skill level to quickly access and use the data.
ONC released data today from the Regional Extension Centers about the different brands of EHR products used by 146,000 doctors by state, specialty, and each doctor’s stage in meaningful use attestation.
HHS is also co-sponsoring a national competition – known as a "code-a-palooza" – to design an innovative app or tool using Medicare data that primary care providers can use to help manage patient care. The national competition, sponsored by ONC, the Health Data Consortium
, and the cloud software company Socrata, will give $25,000 in prizes to the teams of coders and medical experts that build the best tools or apps by the end of Datapalooza.
The Agency for Healthcare Research and Quality (AHRQ) is demonstrating the latest applications of its two powerful health databases, the Healthcare Cost and Utilization Project (HCUP) and the Medical Expenditure Panel Survey (MEPS). HCUP is the largest collection of longitudinal hospital care data in the U.S., representing 97 percent of all inpatient hospital discharges. MEPS is the most complete source of U.S. data on the cost and use of health care services and insurance coverage, obtained through large-scale, annual surveys of families, individuals, medical providers and employers.
ONC in coordination with the Health Resources and Services Administration selected the winners of the Apps4TotsHealth Challenge, which was launched to help parents and caregivers of young children better manage their nutrition and physical activity. The winning developers, researchers, and other innovators make use of Healthdata.gov data to strengthen these tools and make them more user-friendly. More on the winners here.
ONC also announced today the launch of the Blue Button Co-Design Challenge, designed to spur the creation of new applications that will allow patients to better use their own health data to improve their own care. The challenge will ask the public to vote on ideas from which developers will build tools to address health priorities determined by public voting.

SECRETARY OF HHS DUNCAN'S REMARKS ON STUDENT LOAN INTEREST RATE SPIKE

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Statement from Secretary Duncan on Preventing Student Loan Interest Rates from Doubling on July 1

Our priority is to ensure that Congress doesn't allow federal student loan interest rates to double on July 1. President Obama has put forward a comprehensive solution that will help middle-class students and their families afford college by lowering interest rates on July 1, without adding to the deficit, and Senator Harkin and Congressman Miller have also been leaders within Congress to prevent rates from doubling for students and families.

While we welcome action by the House on student loans, we have concerns about its current approach, which does not guarantee low rates for students on July 1, makes students bear the burden of deficit reduction, and fails to lock in interest rates when students take out a loan – so their rates could escalate in the future.

Now is not the time to double interest rates on student loans, and we remain committed to working with Congress on a bipartisan approach to a long-term, fiscally sustainable solution that will help students and families afford higher education now and in the future. Given the impending July 1 deadline, an extension that protects students against higher rates while Congress develops an alternative solution is another reasonable option.

Both the President and I firmly believe college should not be reserved only for the wealthy. All of us share responsibility for making college affordable and keeping the middle-class dream alive. There is no excuse if Congress fails to come to an agreement that prevents rates from rising suddenly in July, and we look forward to working with members of both parties to reach a solution.

CDC SAYS MEAT AND POULTRY ACCOUNT FOR NEARLY A QUARTER OF FOODBORNE ILLNESSES

Credit:  Cattle.  Credit:  USDA

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

From the U.S. Department of Health and Human Services, I’m Nicholas Garlow with HHS HealthBeat.

A study by the Centers for Disease Control and Prevention says meat and poultry account for nearly a quarter of all foodborne illnesses. Beef, what some may think is a common cause of foodborne illness, accounted for only a slice of that.

Dr. John Painter is an epidemiologist at the CDC.

"Beef is now less contaminated to start with, and most fast food restaurants are cooking burgers well so, beef was the source of fewer than seven percent of food-related illnesses and fewer than four percent of deaths."

You still need to be careful to cook beef, especially ground beef, thoroughly. If not completely cooked, contaminated meat and poultry can cause diarrhea.

"And it can be prevented through thoroughly cleaning hands, knives, cutting boards, counters, and sinks after working with raw meat and poultry."

HHS GUARANTEE FOR NEW MEDICAID BENEFICIARIES

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
March 29, 2013
HHS finalizes rule guaranteeing 100 percent funding for new Medicaid beneficiaries

Health and Human Services (HHS) Secretary Kathleen Sebelius today announced a final rule with a request for comments that provides, effective January 1, 2014, the federal government will pay 100 percent of the cost of certain newly eligible adult Medicaid beneficiaries. These payments will be in effect through 2016, phasing down to a permanent 90 percent matching rate by 2020. The Affordable Care Act authorizes states to expand Medicaid to adult Americans under age 65 with income of up to 133 percent of the federal poverty level (approximately $15,000 for a single adult in 2012) and provides unprecedented federal funding for these states.

"This is a great deal for states and great news for Americans," HHS Secretary Kathleen Sebelius said. "Thanks to the Affordable Care Act, more Americans will have access to health coverage and the federal government will cover a vast majority of the cost. Treating people who don’t have insurance coverage raises health care costs for hospitals, people with insurance, and state budgets."

Today’s final rule provides important information to states that expand Medicaid. It describes the simple and accurate method states will use to claim the matching rate that is available for Medicaid expenditures of individuals with incomes up to 133 percent of poverty and who are defined as "newly eligible" and are enrolled in the new eligibility group. The system is set up to make eligibility determinations as simple and accurate as possible for state programs.

Under the Affordable Care Act, states that cover the new adult group in Medicaid will have 100 percent of the costs of newly eligible Americans paid for by the federal government in 2014, 2015, and 2016. The federal government’s contribution is then phased-down gradually to 90 percent by 2020, and remains there permanently. For states that had coverage expansions in effect prior to enactment of the Affordable Care Act, the rule also provides information about the availability of an increased FMAP for certain adults who are not newly eligible.

The rule builds on several years of work that HHS has done to support and provide flexibility to states’ Medicaid programs ahead of the 2014 expansion, including:
90 percent matching rate for states to improve eligibility and enrollment systems;
More resources and flexibility for states to test innovative ways of delivering care through Medicaid;
More collaboration with states on audits that track down fraud; and
Specifically outlining ways states can make Medicaid improvements without going through a waiver process.

HHS REVIEWS MEDITATION AND INFLAMATION

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
From the U.S. Department of Health and Human Services, I’m Ira Dreyfuss with HHS HealthBeat

A study indicates mindfulness meditation might benefit people with chronic inflammatory diseases by reducing the level of inflammation.

At the University of Wisconsin-Madison, Melissa Rosenkranz looked at data on about 60 people. About half got eight weeks of mindfulness training. The others were in a control group that got similar activities but without the mindfulness aspect. Mindfulness is a way to be in the moment without judging things such as how you feel emotionally about them.

Rosenkranz reports:

"Those who participated in the mindfulness training had a smaller post-intervention inflammatory response relative to those who participated in the control intervention."

The study in the journal Brain, Behavior and Immunity was supported by the National Institutes of Health.

HHS SAYS 1 IN 6 PEOPLE WILL GET SICK FROM A FOODBORNE ILLNESS THIS YEAR

FROM: U.S DEPARTMENT OF HEALTH AND HUMAN RESOURCES
From the U.S. Department of Health and Human Services, I’m Nicholas Garlow with HHS HealthBeat.

One in 6 people will get a foodborne illness this year. A new study at the Centers for Disease Control and Prevention looked at which foods are more likely to make us sick. Produce accounted for nearly half of all illnesses. Poultry and meat accounted for the most deaths.

Dr. John Painter is an epidemiologist at the CDC.

"Keep eating your vegetables. As it turns out, many foodborne illnesses are attributed to vegetables, but one reason for that is we eat so many of them."

Contamination of food can occur anywhere from the farm to the table. But you can protect yourself by taking these steps: Wash your hands and food prep surfaces. Separate raw meat, poultry, seafood, and eggs from foods that will not be cooked. Cook and chill foods to proper temperatures.

HHS SAYS STUDY FINDS LOWER SALT CONSUMPTION WOULD SAVE LIVES

Photo Credit:   Wikimedia Commons.

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
I’m Ira Dreyfuss with HHS HealthBeat.

Researchers looking at three computer models have figured out what would happen if we all started to use a little less sodium – commonly, salt – in our food. At the University of California, San Francisco, Pamela Coxson had the computer models assume we could work our way, a bit at a time, to the dietary equivalent of a half teaspoon less salt a day over 10 years:

"All three models predicted mortality reductions on the order of hundreds of thousands of avoided deaths over the 10 years."

That’s up to a half million lives.

Most of the sodium we get is in prepared foods and meals out, so it pays to look hard at the nutrition labeling.

The study in the journal Hypertension was supported by the Centers for Disease Control and Prevention.

HHS CLAIMS MANY GET SICK DUE TO IMPROPER FOOD HANDLING

Photo Credit:  FDA

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
From the U.S. Department of Health and Human Services, I’m Nicholas Garlow with HHS HealthBeat.

Eat and be well? The Centers for Disease Control and Prevention says that, each year, 1 in 6 of us gets sick from food, largely due to improper handling and cooking of ingredients.

At the CDC, researcher Hannah Gould:

"Four foods have been linked to many outbreaks in the last two years. Beef, poultry, such as chicken and turkey, milk, particularly milk th at hasn’t been pasteurized, and fish."

Gould says you can’t tell when something has gone bad just by looking and smelling. So she says the best treatment is prevention in preparation. Clean by washing your hands and food prep surfaces. Separate so meat doesn’t touch vegetables. And cook and chill to correct temperatures.

An article on food handling is in CDC’s Morbidity and Mortality Weekly Report.

HHS HealthBeat is a production of the U.S. Department of Health and Human Services. I’m Nicholas Garlow.

Last revised: March 12, 2013

HHS SAYS 71 MILLION AMERICANS WILL RECEIVE PREVENTITIVE CARE DUE TO AFFORDABLE CARE ACT

Credit:  Veterans Affairs

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Affordable Care Act extended free preventive care to 71 million Americans with private health insurance
Health Care Law’s third anniversary sees health costs slowing down, more value for consumers

Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that about 71 million Americans in private health insurance plans received coverage for at least one free preventive health care service, such as a mammogram or flu shot, in 2011 and 2012 because of the Affordable Care Act. The new data was released in a report from HHS today.

Additionally, an estimated 34 million Americans in traditional Medicare and Medicare Advantage plans have received at least one preventive service, such as an annual wellness visit at no out of pocket cost because of the health care law.

Taken together, this means about 105 million Americans with private health plans and Medicare beneficiaries have been helped by the Affordable Care Act’s prevention coverage improvements.

Preventive services, consumer protections, and other reforms under the Affordable Care Act are giving millions of Americans of all ages more value for their health care dollars and contributing to the slowest growth in health care costs in 50 years.

"Preventing illnesses before they become serious and more costly to treat helps Americans of all ages stay healthier," Secretary Sebelius said. "No longer do Americans have to choose between paying for preventive care and groceries."

Secretary Sebelius released the preventive services report as HHS celebrates the Affordable Care Act’s third anniversary this week. The law is keeping down costs and providing more value for consumers and taxpayers through new consumer protections, holding insurance companies accountable, building a smarter health care system, and providing seniors with vital savings on their prescription drugs.

The Affordable Care Act is giving Americans better value for their health insurance plans by:
Eliminating lifetime dollar caps on essential health benefits, and phasing out annual caps. About 105 million Americans no longer have to fear their benefits will disappear when they need them most because their insurer put a lifetime cap on the amount it would pay.
Prohibiting health insurance companies from denying coverage to children based on a pre-existing condition, such as asthma or cancer.
And in 2014, it will be illegal for health insurance companies to deny coverage to any American or to charge more because of a pre-existing condition. No longer will 129 million Americans with health conditions have to fear seeing their premiums increased or getting locked out of the insurance market.
The law will also make it illegal for a health insurer to charge women more simply because they are women. "That means," Secretary Sebelius said, "being a woman will no longer be a pre-existing condition."

ESTABLISHMENT OF NEW HEALTH INSURANCE MARKETPLACES CONTINUES

Photo Credit:  U.S. Navy.

FROM: U.S. HEALTH AND HUMAN SERVICES
HHS and states move forward to offer quality, affordable health coverage

Health and Human Services (HHS) Secretary Kathleen Sebelius today announced that more states are moving forward to implement the health care law and establishing Health Insurance Marketplaces. HHS conditionally approved Iowa, Michigan, New Hampshire, and West Virginia to operate State Partnership Marketplaces, which will be ready for open enrollment in October 2013.

"HHS will continue to work collaboratively with all states to build the Marketplace," Secretary Sebelius said. "Working together, we will be ready in seven months when consumers will be able to use the new marketplace to easily purchase quality, affordable health insurance plans."

Today’s conditional approvals bring the total number of states that have been conditionally approved to partially or fully run their Marketplace to 24 states and the District of Columbia. In addition, several other states have suggested their own approaches to contributing toward plan management in their Marketplace in 2014. HHS will continue to provide all states with the flexibility, resources, and time needed to support the establishment of the new health insurance marketplace.

Consumers in every state will soon be able to buy insurance from qualified health plans directly through a Marketplace and may be eligible for premium tax credits and cost sharing assistance to help lower their costs. These health plans will ensure consumers have the same kinds of valuable insurance choices as members of Congress, and cannot be denied coverage because of a pre-existing condition.

 

HHS WARNS HELATH SCAMS CAN BE DANGEROUS

Photo:  Rattlesnake.  Credit:  Wikmedia Commons.

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

From the U.S. Department of Health and Human Services, I’m Ira Dreyfuss with HHS HealthBeat.

This’ll cure you? Or make you lose weight?

Not necessarily. Health scammers are good at taking your money and bad at delivering what they promise. So a smart shopper has to tell the difference between what looks good in the ad or on the Net and what the product really is.

At the U.S. Food and Drug Administration, Gary Coody is an expert in detecting health fraud. He says that, if it’s an unproven or little-known treatment, ask your doctor.

"Alarms should go off when you see words like ‘new discovery’ or ‘scientific breakthrough’ or ‘secret ingredient’ or ‘all natural miracle cure.’’’

Because it’s not just the money you can lose. Some of the fakes can be dangerous. And relying on the fakes can delay getting real treatment, while the condition you want to treat just gets worse

HHS SAYS NEW HEALTH CARE LAW PROTECTS CONSUMERS

Credit:  U.S. Army.

FROM: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health care law protects consumers against worst insurance practices
Key health insurance protections for all Americans moves forward

The U.S. Department of Health and Human Services (HHS) today issued a final rule that implements five key consumer protections from the Affordable Care Act, and makes the health insurance market work better for individuals, families, and small businesses.

"Because of the Affordable Care Act, being denied affordable health coverage due to medical conditions will be a thing of the past for every American," said HHS Secretary Kathleen Sebelius. "Being sick will no longer keep you, your family, or your employees from being able to get affordable health coverage."

Under these reforms, all individuals and employers have the right to purchase health insurance coverage regardless of health status. In addition, insurers are prevented from charging discriminatory rates to individuals and small employers based on factors such as health status or gender, and young adults have additional affordable coverage options under catastrophic plans.

Today’s final rule implements five key provisions of the Affordable Care Act that are applicable to non-grandfathered health plans:
Guaranteed Availability
Nearly all health insurance companies offering coverage to individuals and employers will be required to sell health insurance policies to all consumers. No one can be denied health insurance because they have or had an illness.
Fair Health Insurance Premiums
Health insurance companies offering coverage to individuals and small employers will only be allowed to vary premiums based on age, tobacco use, family size, and geography. Basing premiums on other factors will be illegal. The factors that are no longer permitted in 2014 include health status, past insurance claims, gender, occupation, how long an individual has held a policy, or size of the small employer.
Guaranteed Renewability
Health insurance companies will no longer refuse to renew coverage because an individual or an employee has become sick. You may renew your coverage at your option.
Single Risk Pool
Health insurance companies will no longer be able to charge higher premiums to higher cost enrollees by moving them into separate risk pools. Insurers are required to maintain a single state-wide risk pool for the individual market and single state-wide risk pool for the small group market.
Catastrophic Plans
Young adults and people for whom coverage would otherwise be unaffordable will have access to a catastrophic plan in the individual market. Catastrophic plans generally will have lower premiums, protect against high out-of-pocket costs, and cover recommended preventive services without cost sharing.
In preparation for the market changes in 2014 and to streamline data collection for insurers and states, the final rule amends certain provisions of the rate review program. And, HHS has increased the transparency by directing insurance companies in every state to report on all rate increase requests. A new report has found that the law’s transparency provisions have already resulted in a decline in double-digit premium increases filed: from 75 percent in 2010 to, according to preliminary data, 14 percent in 2013.

In addition, today the U.S. Department of Labor announced an interim final rule in the Federal Register that provides protection to employees against retaliation by an employer for reporting alleged violations of Title I of the Act or for receiving a tax credit or cost-sharing reduction as a result of participating in a Health Insurance Exchange, or Marketplace.

HEALTH CARE FRAUD PAYS, THE GOVERNEMNT IN RECOVERIES

FROM: U.S. DEPARTMENTOF HEALTH AND HUMAN SERVICES

Departments of Justice and Health and Human Services announce record-breaking recoveries resulting from joint efforts to combat health care fraud

Government Teams Recovered $4.2 Billion in FY 2012

WASHINGTON – Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius today released a new report showing that for every dollar spent on health care-related fraud and abuse investigations in the last three years, the government recovered $7.90. This is the highest three-year average return on investment in the 16-year history of the Health Care Fraud and Abuse (HCFAC) Program.

The government’s health care fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal Year (FY) 2012, up from nearly $4.1 billion in FY 2011, from individuals and companies who attempted to defraud federal health programs serving seniors and taxpayers or who sought payments to which they were not entitled. Over the last four years, the administration’s enforcement efforts have recovered $14.9 billion, up from $6.7 billion over the prior four-year period. Since 1997, the HCFAC Program has returned more than $23 billion to the Medicare Trust Funds.

These findings, released today in the annual HCFAC Program report, are a result of President Obama making the elimination of fraud, waste and abuse, particularly in health care, a top priority for the administration.

The success of this joint Department of Justice and HHS effort was made possible by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste and abuse in the Medicare and Medicaid programs and to crack down on individuals and entities that are abusing the system and costing American taxpayers billions of dollars. These efforts to reduce fraud will continue to improve with new tools and resources provided by the Affordable Care Act.

"This was a record-breaking year for the Departments of Justice and Health and Human Services in our collaborative effort to crack down on health care fraud and protect valuable taxpayer dollars," said Attorney General Holder. "In the past fiscal year, our relentless pursuit of health care fraud resulted in the disruption of an array of sophisticated fraud schemes and the recovery of more taxpayer dollars than ever before. This report demonstrates our serious commitment to prosecuting health care fraud and safeguarding our world-class health care programs from abuse."

"Our historic effort to take on the criminals who steal from Medicare and Medicaid is paying off: We are gaining the upper hand in our fight against health care fraud," said Secretary Sebelius. "This fight against fraud strengthens the integrity of our health care programs and helps us fulfill our commitment to our seniors."

About $4.2 billion stolen or otherwise improperly obtained from federal health care programs was recovered and returned to the Medicare Trust Funds, the Treasury and others in FY 2012. This is an unprecedented achievement for the HCFAC Program, a joint Justice Department and HHS effort to coordinate federal, state and local law enforcement activities to fight health care fraud and abuse.

The administration is also using tools authorized by the Affordable Care Act to fight fraud, including enhanced screenings and enrollment requirements, increased data sharing across the government, expanded recovery efforts for overpayments and greater oversight of private insurance abuses.

Since 2009, the Justice Department and HHS have improved their coordination through HEAT and increased the number of Medicare Fraud Strike Force teams to nine. The Justice Department’s enforcement of the civil False Claims Act and the Federal Food, Drug and Cosmetic Act have produced similar record-breaking results. These combined efforts coordinated under HEAT have expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud. In FY 2012, the two departments continued their series of regional fraud prevention summits, and the Justice Department hosted a training conference for federal prosecutors, FBI agents, HHS Office of Inspector General agents and others.

The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes as well as with chronic fraud by criminals masquerading as health care providers or suppliers. In July, Attorney General Holder and Secretary Sebelius announced the launch of a ground-breaking partnership among the federal government, state officials, leading private health insurance organizations and other health care anti-fraud groups to share information and best practices to improve detection of and prevent payments to scams that cut across public and private payers.

In FY 2012, the Justice Department opened 1,131 new criminal health care fraud investigations involving 2,148 potential defendants, and a total of 826 defendants were convicted of health care fraud-related crimes during the year. The department also opened 885 new civil investigations.

The strike force coordinated a takedown in May 2012 that involved the highest number of false Medicare billings in the history of the strike force program. The takedown involved 107 individuals, including doctors and nurses, in seven cities, who were charged for their alleged participation in Medicare fraud schemes, involving about $452 million in false billings. As a part of the May 2012 takedown, HHS also suspended or took other administrative action against 52 providers using authority under the health care law to suspend payments until an investigation is complete.

Strike force operations in the nine cities where teams are based resulted in 117 indictments, informations and complaints involving charges against 278 defendants who allegedly billed Medicare more than $1.5 billion in fraudulent schemes. In FY 2012, 251 guilty pleas and 13 jury trials were litigated, with guilty verdicts against 29 defendants, in strike force cases. The average prison sentence in these cases was more than 48 months.

The new authorities under the Affordable Care Act granted to HHS and the Centers for Medicare & Medicaid Services (CMS) were instrumental in clamping down on fraudulent activity in health care. In FY 2012, CMS began the process of screening all 1.5 million Medicare-enrolled providers through the new Automated Provider Screening system that quickly identifies ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation to verify the data. As a result, nearly 150,000 ineligible providers have already been eliminated from Medicare’s billing system.

CMS also established the Command Center to improve health care-related fraud detection and investigation, drive innovation and help reduce fraud and improper payments in Medicare and Medicaid.

From May 2011 through the end of 2012, more than 400,000 providers were subject to the new screening requirements and nearly 150,000 lost the ability to bill the Medicare program due to the Affordable Care Act requirements and other proactive initiatives.

The Department of Justice and HHS also continued their successes in civil health care fraud enforcement during FY 2012. The Justice Department’s Civil Division Fraud Section, with their colleagues in U.S. Attorneys’ offices throughout the country, obtained settlements and judgments of more than $3 billion in FY 2012 under the False Claims Act (FCA). These matters included unlawful pricing by pharmaceutical manufacturers, illegal marketing of medical devices and pharmaceutical products for uses not approved by the Food and Drug Administration, Medicare fraud by hospitals and other institutional providers, and violations of laws against self-referrals and kickbacks. This marked the third year in a row that more than $2 billion has been recovered in FCA health care matters. Additionally, the Civil Division’s Consumer Protection Branch, working with U.S. Attorneys’ offices, obtained nearly $1.5 billion in fines and forfeitures, and obtained 14 convictions in matters pursued under the Federal Food, Drug and Cosmetic Act.