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Improper Medicare Payments Under Scrutiny - Health Care Edge: Brought to you by ACS CAN

Improper Medicare Payments Under Scrutiny 

By Sophie Novack and Sam Baker


MO MONEY, MO PROBLEMS: A pair of new reports is putting a spotlight on improper and questionable Medicare payments. The Government Accountability Office reported yesterday Medicare made some $36 billion in improper payments last year -- a 10 percent error rate. Medicaid came in with another $14 billion in improper payments, according to GAO. Meanwhile, the HHS Office of Inspector General took a specific look at Medicare payments to clinical labs, finding more than 1,000 labs that raised at least five red flags. Some of those labs probably have good reasons for their irregular billing, the OIG said, but the findings also raise concerns about fraud. Medicare paid out $1.7 billion in questionable claims, the OIG reported.

Top Health Care News

GAO REPORT: Medicare, Medicaid, and Medicare Advantage accounted for $62.2 billion of the estimated $105 billion in improper payments distributed by the government last year, according to prepared testimony submitted by the Government Accountability Office to Congress. (Elise Viebeck, The Hill)

OIG REPORT: Almost half of the labs that had five or more measures of questionable billing were located in Florida and California -- areas that are known to be vulnerable to Medicare fraud.


DEM SENATORS INTRODUCE HOBBY LOBBY BILL: Sens. Patty Murray and Mark Udall introduced a new Senate bill Wednesday to reverse the Supreme Court's decision and require employers to provide contraception coverage despite religious objection. Reps. Diana DeGette, Jerrold Nadler, and Louise Slaughter will introduce a companion bill in the House.


SURVEY: MOST NEW INSURANCE CUSTOMERS ARE SATISFIED WITH THEIR COVERAGE: The uninsured rate of individuals ages 19 to 64 decreased from 20 percent to 15 percent since before the ACA was implemented, according to a new survey from the Commonwealth Fund.

More surprisingly, the survey found that 73 percent of those who bought private plans and 87 percent of those who signed up for Medicaid said they were somewhat or very satisfied with their new insurance. The majority of both newly insured Republicans and previously insured individuals reported being happy with their new coverage. (Margot Sanger-Katz, New York Times)

INSURERS ARE TRYING OUT NEW PAYMENT MODELS: About $1 of every $5 in reimbursements is being directed to "value-based" programs that reward providers for improving care and lowering costs, according to a survey released Wednesday by Blue Cross Blue Shield Association.


"Aetna, Cigna and UnitedHealth Group, among others, are also all exploring similar ways of rewarding doctors and hospitals, but the move by the Blue Cross plans is significant because of their size in so many markets. The association estimates the plans have arrangements with 215,000 physicians affecting more than 24 million members, including some in Medicare Advantage plans." (Reed Abelson, New York Times)

LAWSUIT ACCUSES CALIFORNIA INSURANCE GIANT OF 'FRAUDULENT' ENROLLMENT PRACTICES: A class action lawsuit filed this week says that Anthem Blue Cross misled millions of enrollees about whether their hospitals and doctors were participating in the insurer's new plans, and did not reveal that many plans would not cover care outside the approved network. (Julie Appleby, Kaiser Health News/San Jose Mercury News/Los Angeles Daily News)

HOW WELL IS THE ACA WORKING?: That's a different question from what people think of the law. (Larry Levitt, JAMA)

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Medicare and Medicaid

THE PRICE TAG FOR MEDICARE IS DECLINING (AND OBAMACARE COULD BE PARTIALLY RESPONSIBLE): The Congressional Budget Office expects the government to spend about $50 billion less on Medicare this year than it projected four years ago. Spending is expected to be $1,000 lower per beneficiary this year than projected in 2010, and 2,400 lower in 2019. (Sarah Kliff, Vox)

CMS GIVES STATES ULTIMATUM ON MEDICAID BACKLOGS: The Centers for Medicare and Medicaid Services has reportedly given six states until next week to tell the agency how they will address ongoing Medicaid enrollment problems that are preventing over one million individuals from receiving coverage, according to documents obtained by Inside Health Policy.

CMS WANTS TO RECOUP MEDICARE ADVANTAGE OVERCHARGES: In light of criticism that the agency overpays Medicare Advantage plans by billions of dollars annually, federal officials are seeking authority to recover the payments to health plans. The draft regulation is set to be published July 14, with a final decision on the proposal due by November 1. (Fred Schulte, Center for Public Integrity)

CMS MAY LIGHTEN PAPERWORK REQUIREMENTS FOR HOME HEALTH CARE: If a rule proposed by CMS is finalized, doctors may not be required to write a narrative summary for patients who need home health care. (Lisa Gillespie, Kaiser Health News)


COVERING CONTRACEPTION MAY NOT BE COST-EFFECTIVE FOR EMPLOYERS: Several studies estimate that the cost of covering contraception for employees is balanced out by not having to pay for pregnancy or child-related care, but this is not necessarily the case. (Austin Frakt, New York Times)

THE SCIENCE BEHIND EMERGENCY CONTRACEPTION: Some religious groups view the prevention of a fertilized egg from implanting on the uterine wall as abortion, but research has found this isn't actually how the contraception methods in question in the Hobby Lobby case work, despite their outdated labeling. (Julia Belluz, Vox)


A CASE FOR ELECTRONIC HEALTH RECORDS: The adoption of EHRs was not associated with patients being billed as "sicker," or with higher payments to Medicare, as feared, according to a new study published in Health Affairs. (Adrianna McIntyre, Vox)

THE RISE OF URGENT CARE: Urgent care clinics have grown quickly into an estimated $14.5 billion business, and investors are scrambling to get involved. (Julie Creswell, New York Times)


STUDY: NEARLY 90,000 ER TRIPS PER YEAR FOR BAD REACTIONS TO PSYCHIATRIC DRUGS: Anti-anxiety medicines and sedatives are the most common causes, according to a study published Wednesday in JAMA Psychiatry. (Lindsey Tanner, Associated Press)

FDA REVIEWS 'OFF-LABEL' DRUG MARKETING RULES: The Food and Drug Administration is aiming to issue new guidelines by the end of the year on the kind of data and information that drug companies should be allowed to give doctors about uses not approved by the agency. (Brady Dennis, Washington Post)

TWO DRUGS SHOW PROMISE IN TREATING ECZEMA AND PSORIASIS: In small drug trials, an experimental drug for eczema lessened the severity of symptoms in 85 percent of those who took it, while a drug for psoriasis decreased severity of symptoms in up to 82 percent of those who took it, according to papers published Wednesday in the New England Journal of Medicine. (Andrew Pollack, New York Times)

Studies and Reports

A new report from Blue Cross Blue Shield Association says that their companies across the country are spending more than $65 billion a year on programs that incentivize better patient health outcomes and reduce waste in health care delivery. The survey results are from 2012; BCBSA will announce the program results through 2013 in the fall of 2014.

A new study from researchers at Boston Children's Hospital found that the Food and Drug Administration approved 20 medications for attention deficit/hyperactivity disorder over the last 60 years based on clinical trials that were not designed to study the drugs' long-term efficacy and safety.

Another wine survey: a new study published in JAMA Internal Medicine found that levels of resveratrol -- found in red wine and chocolate and considered to have antioxidant, anticancer, and anti-inflammatory effects -- in a Western diet did not have a substantial impact on health status and mortality risk.

Happening Today

We're monitoring the U.S. Court of Appeals for the D.C. Circuit for a decision on Halbig v. Sebelius, which could come any day now. The lawsuit challenges the legality of government subsidies for ACA plans on the federal marketplace, and if successful, could have a devastating effect on the health care law.

The House Committee on Veterans' Affairs hearing titled "Service should not lead to suicide: Access to VA's Mental Health Care" at 9:15 a.m.

House Committee on Oversight and Government Reform hearing on Medicare appeals reform at 2 p.m.


Don't Miss Today's Top Stories

Health Care Edge is one of my top resources."

Meghan, Associate Specialist

Great news in short form along with much needed humor."

Patrick, President of private healthcare consulting firm

Informative and help[s] me stay on track. "

Director of Scientific Affairs, Non-profit medicial society

Sign up form for the newsletter