• Category Archives Insurance News
  • The rewards for reporting gross instances of healthcare fraud can be substantial if the proof is very well-documented

    The Corporate Whistleblower Center believes Medicare fraud, or overbilling in the healthcare industry is completely out of control, mainly because of little to no oversight. The group is especially interested in talking to physicians, or employees of companies providing diagnostic testing, imaging, dialysis, or hospice, provided they have very well documented proof of substantial Medicare fraud, or overbilling that is in the hundreds of thousands, or in the millions of dollars. The rewards for this kind of information can be significant. For more information, potential whistleblowers are urged to contact the Corporate Whistleblower Center at 866-714-6466. http://CorporateWhistleblowerCenter.Com

    As an example according to a February 2014 Justice Department press release, Diagnostic Imaging Group (DIG) has agreed to pay a total of $15.5 million to resolve allegations that its diagnostic testing facility falsely billed federal and state health care programs for tests that were not performed or not medically necessary as well as paying kickbacks to physicians.

    The settlement also resolves allegations that DIG paid kickbacks to physicians for the referral of diagnostic tests. According to the government, the kickbacks allegedly were in the form of payments that DIG made to physicians to supervise patients who underwent nuclear stress testing. These payments allegedly exceeded fair market value and were, in fact, intended to reward physicians for their referrals.

    The three whistleblowers in this case will receive $ 1.5 million , $ 1.07 million and $ 209,250 , respectively, as part of this settlement.

    The Corporate Whistleblower Center says, “If you are a medical doctor, or an employee at a diagnostic imaging center, a dialysis center, a rehab center, or any type of healthcare company that is involved in substantial Medicare fraud or overbilling, we definitely want to talk to you, provided you have well detailed proof such as e-mails, accounting records, or documents detailing the fraud. Unlike any group in the US, we will help you package your information, and we will get you to one of the nation’s top whistleblower attorneys.” For more information potential whistleblowers can call the Corporate Whistleblower Center anytime at 866-714-6466. http://CorporateWhistleblowerCenter.Com

    Simple rules for a whistleblower from the Corporate Whistleblower Center:

    • Do not go to the government first if you are a major whistleblower. The Corporate Whistleblower Center says, “Major whistleblowers frequently go to the federal government thinking they will help. It’s a huge mistake.”
    • Do not go to the news media with your whistleblower information. Any public revelation of a whistleblower’s information could destroy any prospect for a whistleblower reward with the DOJ.
    • Do not try to force a government contractor, or corporation to come clean to the government about their wrongdoing. The Corporate Whistleblower Center says, “Fraud is so rampant among federal contractors that any suggestion of exposure might result in an instant job termination, or harassment of the whistleblower. Come to us first, tell us what type of information you have, and if we think it’s sufficient, we will help find the right law firms to assist in advancing your information.”

    Any type of insider or employee who possesses significant proof of their employer or a government contractor defrauding the federal government is encouraged to contact to Corporate Whistleblower Center anytime at 866-714-6466 or via their web site at http://CorporateWhistleBlowerCenter.Com

    For attribution purposes please refer the Justice Department February 2014 press release: http://www.justice.gov/opa/pr/2014/February/14-civ-200.html

    Case Numbers:  The three cases are captioned United States ex rel. Mark Novick, M.D. v. Doshi Diagnostic Imaging Services P.C. , Civil Action No. 09-4992 (D.N.J.), United States ex rel. Rey Solano v. Diagnostic Imaging Group et al., Civil Action No. 10-267 (D.N.J.) and United States ex rel. Richard Steinman, M.D. v. Diagnostic Imaging Group, et al., Civil Action No. 10-4161 (E.D.N.Y.).

    Media Contact:

    M. Thomas Martin, 866-714-6466

    Read more news from the Corporate Whistleblower Center.

    SOURCE Corporate Whistleblower Center


  • Medicare Advantage Cheapest Option for New Medicare Enrollee

     Americans are turning 65 at a pace of 10,000 per day and they face a confusing array of insurance decisions regarding Medicare. To help this age group understand their insurance choices, HealthPocket evaluated the expenses associated with their three main coverage options:

    • Original Medicare with a Medicare drug plan
    • Medigap Plan F with Original Medicare and a Medicare drug plan
    • Medicare Advantage

    Using government data on healthcare and medication use among Medicare-aged individuals, HealthPocket compared the premium and out-of-pocket expenses for each of the three Medicare insurance options. Medicare Advantage proved to be the lowest cost option. Its annualized cost estimate was 19% less than Original Medicare Parts A & B combined with a Medicare drug plan and it was 45% less than Medigap Plan F combined with Medicare Parts A & B and a Medicare drug plan. While the Plan F option left the Medicare enrollee with no medical out-of-pocket costs, this option still had out-of-pocket costs associated with drug coverage. Additionally, the Plan F option’s lower out-of-pocket costs did not compensate for its higher overall premium expenses.

    Due to its current government funding structure, many Medicare Advantage plans do not charge a monthly premium. These plans also include an annual limit on out-of-pocket costs. Original Medicare has no such limit on out-of-pocket costs.

    Premiums and out-of-pocket costs for Medicare Advantage plans may be affected in the future by changes in government funding but these changes are difficult to predict. Medicare Advantage plans have been at the center of highly politicized debates over the program given that the government often spends more for medical services delivered by Medicare Advantage plans as compared to the same services received in Original Medicare.


  • Puget Sound Physicians Rally Behind New Health Insurance Model Promising Better Care, Fairer Reimbursement, and Lower Costs for Employers

    Physician Care Direct partners with employers and health systems to make healthcare more affordable. We deliver the Employer Health Ownership Plan(TM) (EHOP(TM)) an innovative health plan solution that starts with personalized primary care, then adds physician and hospital networks for a comprehensive solution. Now businesses of all sizes can offer their employees meaningful healthcare benefits while controlling and reducing costs. For more information, visit www.physiciancaredirect.com. (PRNewsFoto/Physician Care Direct)Amid news that health insurance premiums will rise for nearly two-thirds of small businesses under the Affordable Care Act, Physician Care Direct today announced that Eastside Family Medicine Clinic has joined several other Puget Sound medical groups in adopting a health plan designed to better manage employer costs while benefiting patients and providers alike.

    The addition of Eastside, a nine-provider group in Bellevue, brings to over 60 the number of Puget Sound primary care providers who have agreed to participate in the Employer Health Ownership Plan™ (EHOP™).

    The EHOP is a healthcare purchasing strategy from Physician Care Direct that encourages greater use of primary care – low-cost medical services that address 90 percent of patients’ needs. Employers buy personalized primary care directly from providers and then add coverage for specialists and hospitalization. The approach ensures that primary care providers are fairly compensated for comprehensive care, while employers share in the savings from keeping employees healthy.

    “Many studies have shown that timely and excellent primary care reduces emergency department visits, specialist visits, hospitalizations and surgeries,” said Antony Engal, MD, president of Eastside Family Medicine Clinic. “It’s about time that someone developed a health plan that recognizes that fact. Physician Care Direct’s approach is unique and one that we hope many more Puget Sound physicians and employers will embrace as they seek to improve the quality of patient care while lowering its cost.”

    How the EHOP Works

    The majority of U.S. companies contract with insurers for healthcare benefits that remain a fixed cost throughout the term of the contract. If they reduce healthcare expenses by encouraging employee wellness, those savings benefit their insurance company. Employers’ premiums rise as health system costs increase, leaving them at the mercy of cost shifting in an inefficient market.

    The problem is especially acute for smaller businesses, which pay between 10 and 18 percent more for health insurance than larger companies, according to the Commonwealth Fund. Compounding the problem, the Centers for Medicare and Medicaid Services announced in late February that nearly two-thirds of small businesses that currently offer health insurance to their workers will pay more for coverage as a result of new rules in the healthcare law, as will millions of small-business employees and their family members.

    Self-insurance under the EHOP can help by converting approximately 60 to 70 percent of a company’s healthcare expense to a variable cost. As a result, when the company and the EHOP succeed in reducing healthcare spending, underwriting profits flow back to the employer not their insurance company. The EHOP can also include reinsurance to limit the employer’s financial risk.

    EHOP participants pay few if any out-of-pocket costs for primary care. Having comprehensive primary care available at no or little cost enables employees to better manage their health and reduce healthcare expenses.

    Hospitals and health systems can offer their own private-label EHOP to employers in their area. The approach lets hospitals become the center of a community-based solution to improve care coordination and health outcomes.

    “We know that timely primary care can improve the health status of Americans and lower costs, yet our healthcare purchasing methods are pricing employers out of business, causing physicians to abandon primary care, and bankrupting patients,” said William Lawson, M.D., CEO of Physician Care Direct. “With the Employer Health Ownership Plan, employers can save up to 30 percent of their costs, providers can practice medicine the way they’ve always wanted to, and employees can minimize their costs by engaging in healthy behaviors. It’s a common sense approach to a problem that’s been needlessly complicated by insurance companies.”

    Along with Eastside, two other primary care medical groups are participating in the EHOP – Family Care Network, based in Bellingham with clinics throughout Whatcom and Skagit counties, and Qliance, an innovative venture capital-backed company that operates five “direct primary care” clinics in the Seattle area.

    Upcoming Presentations on the EHOP

    Physician Care Direct will participate in three upcoming meetings on health insurance reform in Washington State:

    • March 12 at the Matrix Insurance Broker seminar in Seattle.
    • March 25 at the Washington Association of Health Underwriters (WAHU) Spring Symposium, held at the Hilton Seattle Airport & Conference Center in Seattle.
    • March 26 at the Washington Association of Health Underwriters (WAHU) Spring Symposium, held at the Lincoln Center in Spokane.

    At all three events, Christopher Shoffner, Chief Risk Officer for Physician Care Direct, will present “Changing the Way We Pay for Healthcare:  Aligning Incentives and Outcomes.” Shoffner will review the current state of employer health insurance and the benefits of the Employer Health Ownership Plan.

    About Physician Care Direct

    Physician Care Direct partners with employers and health systems to make healthcare more affordable. We deliver the Employer Health Ownership Plan™ (EHOP™)—an innovative health plan solution that starts with personalized primary care, then adds physician and hospital networks for a comprehensive solution.  Now businesses of all sizes can offer their employees meaningful healthcare benefits while controlling and reducing costs. For more information, visit www.physiciancaredirect.com.

    Press Contact:
    Todd Stein
    Amendola Communications
    916-346-4213
    tstein@acmarketingpr.com

    Logo – http://photos.prnewswire.com/prnh/20140310/MM80608LOGO

    SOURCE Physician Care Direct


  • What’s in Store for Health-Care Reform in 2014

    While the Affordable Care Act (ACA) became law in 2010, several of the more substantive provisions of the law don’t take effect until 2014. Here’s a review of some of the key parts of the ACA that are scheduled to begin in 2014.

    Individual mandate

    The ACA imposes a shared responsibility mandate, which requires that most U.S. citizens and legal residents of all ages (including children and dependents) have minimum essential health coverage or pay a penalty tax, unless otherwise exempt. The monthly penalty is equal to the greater of a declared dollar amount ($95 in 2014) or a percentage of the individual’s gross income.

    Note:   The employer’s mandate to provide coverage for employees was also scheduled to begin in 2014; however, the requirement will not be enforced until January 2015.

    State Exchanges

    The ACA requires that each state establish state-based American Health Benefit Exchanges for individuals and Small Business Health Options Program (SHOP) Exchanges for small employers. The Department of Health and Human Services will establish Exchanges in states that do not create the Exchanges. The general purpose of these Exchanges is to provide a single resource in each state for consumers and small businesses to compare health plans, get answers to questions, and enroll in a health plan that is both cost effective and meets their health-care needs.

    Exchanges may only offer qualified health plans that cover essential benefits, limit out-of-pocket costs, and provide coverage based on four levels of cost sharing–bronze, silver, gold, and platinum. Also, tax credits and cost-sharing subsidies will be available to U.S. citizens and legal immigrants who buy health insurance through the health Exchanges.

    Insurers must provide guaranteed issue and renewability of coverage

    All individual and group plans must issue insurance to all applicants regardless of health status, medical condition, or prior medical expenses. Insurers must renew coverage for applicants even if their health status has changed. Grandfathered individual plans are exempt from these requirements. Grandfathered plans are those that were in existence prior to the enactment of the ACA (March 2010) and have not been significantly altered in subsequent years.

    In the past, insurers used pre-existing medical condition provisions to deny coverage for care related to the condition (pre-existing condition policy exclusion), increased the premium to cover the condition, or denied coverage altogether. Beginning January 1, 2014, the ACA prohibits insurers in group markets and individual markets (with the exception of grandfathered individual plans) from imposing pre-existing condition exclusions.

    In keeping with the guaranteed availability of coverage, insurers may not charge individuals and small employers higher premiums based on health status or gender. Premiums may vary only based on family size, geography, age, and tobacco use.

    Essential health benefits

    All nongrandfathered small group and individual health plans must offer a package of essential health benefits from 10 benefit categories. The categories include ambulatory patient services, emergency services, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitative services and devices, preventive and wellness services, and pediatric services, including dental and vision.

    Other policy provisions

    The ACA also imposes several requirements and eliminates other provisions commonly found in insurance policies:

    • Group and individual policies (including grandfathered plans) may not impose waiting periods longer than 90 days before coverage becomes effective.
    • Annual deductible for small group (fewer than 50 full-time equivalent employees) health plans (excluding grandfathered plans) must not exceed $2,000 per insured and $4,000 per family. These amounts are indexed to increase in subsequent years.
    • The most you’ll pay annually for out-of-pocket expenses (deductibles, coinsurance, and co-pays) for all individual and group health plans (excluding grandfathered plans) cannot exceed the maximum out-of-pocket limits for health savings accounts ($6,350 for individual/$12,700 for family in 2014).
    • All group health plans and nongrandfathered individual health plans can no longer impose annual or lifetime dollar limits on essential health benefits.

  • Blue Shield Imposes Another Unreasonable Rate Hike, This Time On More Than 80,000 Californians says Consumer Watchdog

    Blue Shield Life and Health is imposing an unreasonable rate increase on over 80,000 Californians with individual health insurance policies, an average of 9.8% that adds up to a 22.8% increase for the year. California Insurance Commissioner Dave Jones announced today that the company would not budge on its excessive rate hike. Working with an independent actuary, AIS Risk Consultants, the nonprofit, nonpartisan Consumer Watchdog analyzed the data in Blue Shield’s rate filing and found that the company’s projections of future health costs were too high, its planned administrative costs were excessive, and that the insurer had failed to provide data to back up many of its assumptions. The U.S. Centers for Medicare and Medicaid Services released new data yesterday that showed health care spending growth slowed in 2012 for the fourth year in a row, to less than 4%. “Blue Shield has made overblown projections of health care costs and padded its overhead to impose higher rates that cannot be justified, even as health care cost growth continues to hit record lows,” said Carmen Balber, Executive Director with Consumer Watchdog. “Unfortunately California’s insurance commissioner, unlike those in 35 other states, has no power to stop insurers from overcharging consumers.” This is not the first time Blue Shield Life and Health has imposed an excessive rate increase on consumers, nor is it the first time that the company has been penalized for excessive administrative costs. In March of 2013, Blue Shield Life and Health raised rates as much as 19.9% on 268,000 Californians, an increase that the insurance commissioner also found to be unreasonable. In 2012, Blue Shield Life and Health failed to spend at least 80% of consumers’ premiums on health care, as required by the Affordable Care Act, and had to return $13.3 million to California individual and family policyholders. The group also noted that Blue Shield of California, the parent company of Blue Shield Life and Health, is in a position of notable financial strength. Blue Shield of California has amassed a total net worth of $3.86 billion. At the end of 2012, Blue Shield of California had excess surplus of about $3.39 billion – an amount that is 1561% more than the state requires.