Opioid Case With 2 Ohio Counties As Plaintiffs Set To Go To Trial Next Week
The first federal case against the opioid industry goes to trial Monday. Some companies have settled to avoid trial, others will get their day in court.
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Whistleblower Alleges Fraud At A Large Medicare Advantage Plan In Seattle
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Group Health Cooperative in Seattle, one of the United States’ oldest and most respected nonprofit health insurance plans, is accused of bilking Medicare out of millions of dollars in a federal whistleblower case.
Teresa Ross, a former medical billing manager at the insurer, alleges that it sought to reverse financial losses in 2010 by claiming that some patients were sicker than they were or by billing for medical conditions that patients didn’t actually have. As a result, the insurer retroactively collected an estimated $8 million from Medicare for 2010 services, according to the suit.
Ross filed suit in federal court in Buffalo, N.Y., in 2012, but the suit remained under a court seal until July and is in its initial stages. The suit also names as defendants two medical coding consultants — consulting firm DxID of East Rochester, N.Y., and Independent Health Association, an affiliated health plan in Buffalo, N.Y. All denied wrongdoing in separate court motions filed late Wednesday to dismiss the suit.
The Justice Department has thus far declined to take over the case but said in a June 21 court filing that “an active investigation is ongoing.”
The whistleblower suit is one of at least 18 such cases documented by Kaiser Health News that accuse Medicare Advantage managed care plans of ripping off the government by exaggerating how sick their patients were. The whistleblower cases have emerged as a primary tool for clawing back overpayments. While many of the cases are pending in courts, five have recovered a total of nearly $360 million.
“The fraudulent practices described in this complaint are a product of the belief, common among [Medicare Advantage] organizations, that the law can be violated without meaningful consequence,” Ross alleges.
Medicare Advantage plans are a privately run alternative to traditional Medicare that often offer extra benefits such as dental and vision coverage but limit choice of medical providers. They have exploded in popularity in recent years, enrolling more than 22 million people, just over 1 in 3 of those eligible for Medicare.
Word of another whistleblower alleging Medicare Advantage billing fraud comes as the White House is pushing to expand enrollment in the plans. On Oct. 3, President Trump issued an executive order that permits the plans to offer a range of new benefits to attract patients. One, for instance, is partly covering the cost of Apple watches as an inducement.
Group Health opened for business more than seven decades ago and was among the first managed care plans to contract with Medicare. Formed by a coalition of unions, farmers and local activists, the HMO grew from just a few hundred families to more than 600,000 patients before its members agreed to join California-based Kaiser Permanente. That happened in early 2017, and the plan is now called Kaiser Foundation Health Plan of Washington. (Kaiser Health News is not affiliated with Kaiser Permanente.)
In an emailed statement, a Kaiser Permanente spokesperson said: “We believe that Group Health complied with the law by submitting its data in good faith, relying on the recommendations of the vendor as well as communications with the federal government, which has not intervened in the case at this time.”
Ross nods to the plan’s history, saying it has “traditionally catered to the public interest, often highlighting its efforts to support low-income patients and provide affordable, quality care.”
The insurer’s Medicare Advantage plans “have also traditionally been well regarded, receiving accolades from industry groups and Medicare itself,” according to the suit.
But Ross, who worked at Group Health for more than 14 years in jobs involving billing and coding, says that from 2008 through 2010, the company “went from an operating income of almost $57 million to an operating loss of $60 million.” Ross says the losses were “due largely to poor business decisions by company management.”
The lawsuit alleges that the insurer manipulated a Medicare billing formula known as a risk score. The formula is supposed to pay health plans higher rates for sicker patients, but Medicare estimates that overpayments triggered by inflated risk scores have cost taxpayers $30 billion over the past three years alone.
According to Ross, a Group Health executive in 2011 attended a meeting of the Alliance of Community Health Plans, where he heard from a colleague at Independent Health about an “exciting opportunity” to increase risk scores and revenue. The colleague said Independent Health “had made a lot of money” using its consulting company, which specializes in combing patient charts to find overlooked diseases that health plans can bill for retroactively.
In November 2011, Group Health hired the firm DxID to review medical charts for 2010. The review resulted in $12 million in new claims, according to the suit. Under the deal, DxID took a percentage of the claims revenue it generated, which came to about $1.5 million that year, the suit says.
Ross says she and a doctor who later reviewed the charts found “systematic” problems with the firm’s coding practices. In one case, the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.” Overall, about three-quarters of its claims for higher charges in 2010 were not justified, according to the suit. Ross estimated that the consultants submitted some $35 million in new claims to Medicare on behalf of Group Health for 2010 and 2011.
In its motion to dismiss Ross’ case, Group Health called the matter a “difference of opinion between her allegedly ‘conservative’ method for evaluating the underlying documentation for certain medical conditions and her perception of an ‘aggressive’ approach taken by Defendants.”
Independent Health and the DxID consultants took a similar position in their court motion, arguing that Ross “seeks to manufacture a fraud case out of an honest disagreement about the meaning and applicability of unclear, complex, and often conflicting industry-wide coding criteria.”
In a statement, Independent Health spokesman Frank Sava added: “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately.”
Whistleblowers sue on behalf of the federal government and can share in any money recovered. Typically, the cases remain under a court seal for years while the Justice Department investigates.
Heading Out On The Ice With Adam Rippon
Last year, Adam Rippon accomplished one of his biggest goals: heading to the Winter Olympics in Pyeongchang.
He medaled, even though he was a decade older than his teammates.
And while he was there, he became a star. He started by calling himself “America’s sweetheart.” And soon enough, he was.
His viral moments and charm offensive didn’t stop with the Olympics. He turned heads and made headlines when he wore a leather harness to the 2018 Oscars. And he brought his dynamic grace to “Dancing with the Stars.”
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He officially stopped skating earlier this year. Now, he’s out with a new memoir called Beautiful On The Outside, and has a brand new show cooking about celebrity throwback moments.
Rippon joins us to talk about his road to the Olympics and beyond.
Produced by Chris Castano and Gabrielle Healy.
Golfer Adds Big Penalties For Standing Caddie
Lee Ann Walker had to add penalty strokes for having her caddie stand behind her as she putted in a tournament in French Lick, Ind. She wasn’t aware of the rule change.
Hospital Giant Sutter Health Agrees To Settlement In Big Antitrust Fight
California Attorney General Xavier Becerra, along with 1,500 self-funded health plans, sued Sutter Health for antitrust violations. The closely watched case, which many expected to set precedents nationwide, ended in a settlement Wednesday. Above, Sutter Medical Center in Sacramento, Calif.
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Rich Pedroncelli/AP
Sutter Health, a large nonprofit health care system with 24 hospitals, 34 surgery centers and 5,500 physicians across Northern California, has reached a preliminary settlement agreement in a closely watched antitrust case brought by self-funded employers and later joined by California’s Office of the Attorney General.
The agreement was announced in San Francisco Superior Court on Wednesday, just before opening arguments were expected to begin.
Details have not been made public, and the parties declined to talk to reporters. Superior Court Judge Anne-Christine Massullo told the jury that details likely will be made public during approval hearings in February or March.
There were audible cheers from the jury following the announcement that the trial, which was expected to last for three months, would not continue.
Sutter, which is based in Sacramento, Calif., stood accused of violating California’s antitrust laws by using its market power to illegally drive up prices.
Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California, Berkeley, that was cited in the complaint.
The case was a massive undertaking, representing years of work and millions of pages of documents, California Attorney General Xavier Becerra said before the trial. Sutter was expected to face damages of up to $2.7 billion.
Sutter Health consistently denied the allegations and argued that it used its market power to improve care for patients and expand access to people in rural areas. The chain of health care facilities had $13 billion in operating revenue in 2018.
The case was expected to have nationwide implications on how hospital systems negotiate prices with insurers. It is not yet clear what effect, if any, a settlement agreement would have on Sutter’s tactics or those of other large systems.
Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.
Doctors Faced With Tough Decisions Due To Shortage Of Drug Used To Treat Cancer
NPR’s Audie Cornish speaks with Dr. Yoram Unguru, a hematologist and oncologist in Baltimore, about a shortage of vincristine, a drug used to treat childhood cancer.
Washington Nationals Head To The World Series For The 1st Time
There’s not a lot that folks in Washington, D.C., seem to be able to agree on except one thing: there’s plenty of excitement about the Nationals making it to the World Series for the first time.
Poor People Are Still Sicker Than The Rich In Germany, Despite Universal Health Care
In Hamburg, Germany, estimated life expectancy in the city’s poorer neighborhoods still trails wealthier neighborhoods by 13 years.
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Juergen Sack/Getty Images
Researchers around the world hail Germany for its robust health care system: universal coverage, plentiful primary care, low drug prices and minimal out-of-pocket costs for residents.
Unlike in the U.S., the prospect of a large medical bill doesn’t stand in the way of anyone’s treatment.
“Money is a problem in [their lives], but not with us,” says Merangis Qadiri, a health counselor at a clinic in one of the poorest neighborhoods in Hamburg, in northern Germany.
But it turns out that tending to the health needs of low-income patients still presents universal challenges.
As an American health care reporter traveling through Germany, I wanted to learn not only what works, but also where the system falls short. So when I arrived here — in one of the country’s wealthiest cities, with one of its largest concentrations of doctors — economists and researchers directed me to two of the poorest neighborhoods: Veddel and Billstedt, both home to high populations of recent immigrants.
Entering these areas felt like stepping into another city, where even though people have universal insurance, high rates of chronic illnesses such as diabetes, depression and heart disease persist. Treatment and preventive care are difficult to access.
The challenges faced at both outposts ? Poliklinik Veddel and Gesundheit für Billstedt/Horn (literally, “Health for Billstedt and Horn”) ? underscore a point: Universal health care, in and of itself, may be a first step toward increasing a community’s health, but it isn’t a magical solution.
Life expectancy in these areas is estimated to trail that of Hamburg’s wealthier neighborhoods by 13 years ? roughly equivalent to the gap between Piedmont, a particularly wealthy suburb of Oakland, Calif., and its more urban neighbor, West Oakland. In Hamburg, the difference persists even though residents never skip medication or doctors’ visits because of cost.
Medical care is only part of the equation. An array of other factors ? known collectively as the “social determinants of health” ? factor strongly into these populations’ well-being. They include big-picture items like affordable, nutritious food and safe areas to exercise — as well as small ones, like having the time and money to get to the doctor.
In Germany, as in the U.S., these are exceptionally difficult problems to treat.
In its three years of operation, Gesundheit für Billstedt/Horn has been visited by about 3,500 patients — 3% of the population in the two neighborhoods it serves. And maybe half of the people who come for a first visit return for a follow-up, says Qadiri, who works at Billstedt/Horn.
For one thing, many don’t know the health outpost exists. For another, people might not feel they can spare the time from chaotic lives.
To address that problem, the Billstedt site, with its patient rooms up front and a large meeting space in the back, is situated in a bustling mall among shops that include an Afghan bakery, Turkish restaurant and McDonald’s. The outpost doesn’t have doctors onsite, but it employs health counselors, who offer advice on healthy living and guidance on how patients can manage chronic conditions, and communicate with patients’ physicians as needed.
The Poliklinik, located in a separate neighborhood known as Veddel, uses social and community events to get patients in the door. The clinic organizes coffees, shows up at local church events and holds local movie nights. The strategy appears to work, at least somewhat: By 11 a.m. on a Tuesday morning, the brightly decorated waiting rooms are filled with patients waiting to see a doctor or other health professional.
The Hamburg neighborhood of Veddel, a 20-minute bike ride from the city’s downtown, is home to many recent immigrants.
Shefali Luthra/Kaiser Health News
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Shefali Luthra/Kaiser Health News
Still, Poliklinik sees only about 850 unique patients every three months, far short of the area’s 5,000 residents, says Dr. Phillip Dickel, a general practitioner at the clinic.
Another limit on the clinic’s ability to meet need: a shortage of doctors willing to work in this part of town. That includes general practitioners, to say nothing of gynecologists, mental health specialists and pediatricians ? few of whom practice in the area, he adds. In theory, one could take public transit to another part of the city to find a doctor, but that involves time and money for the commute.
Meanwhile, the environmental problems that plague these areas are in some ways more intractable, Dickel says.
Poliklinik’s neighborhood, for instance, is just off the autobahn and filled with old industrial warehouses and factories.
That creates lower air quality and higher risks of asthma and lung diseases, Dickel says. Patients in all these neighborhoods confront housing shortages, so families become overcrowded in small flats. Aside from the psychological toll, illnesses and infections ? influenza, a cold or something more serious ? spread quickly.
While the clinics advocate for improved housing, sometimes the best the staffers at the clinics can do is give advice on how to minimize housing-related health risks.
Qadiri, the Gesundheit health counselor, tries to help patients with diabetes and heart disease find and incorporate fruits and vegetables in their diets and teaches them strategies to replace sugary beverages. She also encourages them to attend onsite exercise classes.
But nutritious food is harder to find in the areas these clinics serve than in one of Hamburg’s wealthier neighborhoods. And fresh produce costs more than fast food.
“People can get care in Germany if they need it,” Dickel says. “Much more important [than access], I would say, are the social conditions. That’s the cause of the life-expectancy gap.”
The Arthur F. Burns Fellowship is an exchange program for German, American and Canadian journalists operated by the International Center for Journalists and the Internationale Journalisten-Programme.
Kaiser Health News a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.
Controversial Referee Call Helped Green Bay Win Monday Night Football
The NFL admits a disputed call during Monday night’s game between Detroit and Green Bay was a mistake by the officials. The league has been criticized all season for referee blunders.
RACHEL MARTIN, HOST:
The NFL admits that officials made a mistake. It happened during Monday night’s game between Detroit and Green Bay. Referees made a call that helped Green Bay win. It’s the latest officiating kerfuffle this season that has frustrated players and fans. But what can be done? Here’s NPR’s Tom Goldman.
TOM GOLDMAN, BYLINE: Monday night, Detroit Lions defensive lineman Trey Flowers was penalized twice for illegal hands to the face. Replays showed his hands were locked on his opponent’s shoulder pads, not the face. ESPN “Monday Night Football” analyst Booger McFarland reacted strongly, especially after the second penalty was called late in the game.
(SOUNDBITE OF ARCHIVED RECORDING)
ANTHONY MCFARLAND: And he shouldn’t have been called tonight. Let’s make sure we let America know that That’s twice. The first time it cost them a sack; this time it cost them the game.
GOLDMAN: America got the message, tweeting lots of angry stuff about the NFL and officials. That’s been a thing, really, since last season’s NFC championship game, when the New Orleans Saints were the aggrieved party after an obviously blown no-call by the refs. What to do? There have been discussions about placing a so-called sky judge in each stadium, an official high above the field watching on TV like the rest of us.
JUDY BATTISTA: Coaches like the idea of sky judges. You have somebody in the stadium who has final authority.
GOLDMAN: But NFL.com’s Judy Battista says there’s also concern that sky judges would weaken officiating on the field and not be consistent from stadium to stadium. Calling NFL games is hard. The action is high-speed, and officials don’t have the luxury of watching on high-def TVs with endless replays and multiple camera angles. But Battista says recent retirements by experienced officials have had an impact.
BATTISTA: There’s no question that inexperience plays a role in some of this.
GOLDMAN: The NFL is aware of the officiating issues. But there’s also a strong belief, repeated often, that mistakes will happen in a game officiated by human beings – true, but little solace to sad and angry Detroit Lions fans.
Tom Goldman, NPR News.
(SOUNDBITE OF EDO.G’S “SITUATIONS”)
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Back From China, LeBron James Speaks Out On NBA Controversy
Los Angeles Lakers forward LeBron James, shown here during a game on Monday, has weighed in on comments made by Houston Rockets General Manager Daryl Morey.
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Mark J. Terrill/AP
Los Angeles Lakers star LeBron James has criticized a tweet sent by Houston Rockets General Manager Daryl Morey in support of Hong Kong protesters, saying of Morey, “I believe he wasn’t educated on the situation at hand.”
James has just returned from the NBA’s tense trip to China, where teams played exhibition games but many player appearances were canceled owing to the controversy over Morey’s statement, which was deleted shortly after it was posted.
“Yes, we all do have freedom of speech, but at times there are ramifications for the negative that can happen when you’re not thinking about others and you’re only thinking about yourself,” James told reporters in Los Angeles.
“I don’t want to get into a word or sentence feud with Daryl, with Daryl Morey, but I believe he wasn’t educated on the situation at hand and he spoke,” James said. He added, “And so many people could have been harmed, not only financially but physically, emotionally, spiritually.”
James’ comments quickly met with criticism in the U.S. and beyond. For example, Michael David Smith from Pro Football Talk tweeted, “Morey literally was thinking about others. He was thinking about the people of Hong Kong, who want the same freedoms Americans take for granted.”
James has previously spoken out about social issues in the U.S., including police shootings of black men and the far-right rally in Charlottesville, Va. But his latest comments have drawn criticism in the U.S. and outrage from protesters in Hong Kong. On Tuesday, a protester brandished a sign at a demonstration that showed James embracing a Chinese banknote.
A demonstrator holds a sign showing Lebron James embracing a Chinese 100-yuan banknote during a rally in Hong Kong on Tuesday.
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Mark Schiefelbein/AP
In his remarks, James did not engage with the specific message of Morey’s tweet, which said, “Fight for Freedom. Stand with Hong Kong.” He appeared to be speaking primarily about the Chinese backlash that targeted the broader NBA — including James’ team. The Lakers played a preseason game in Shenzhen on Saturday, but Chinese networks refused to broadcast it, and the NBA canceled news conferences related to the game.
Morey’s remarks supporting pro-democracy protesters in Hong Kong caused major backlash from China ahead of an exhibition series there between the Lakers and the Brooklyn Nets. The NBA has been seeking to expand its fan base in the country. But as NPR reported, the NBA’s media partner in China, Tencent, said it wouldn’t air any Rockets games, in addition to dropping the two preseason games played in China.
My team and this league just went through a difficult week. I think people need to understand what a tweet or statement can do to others. And I believe nobody stopped and considered what would happen. Could have waited a week to send it.
— LeBron James (@KingJames) October 15, 2019
James said players on the overseas trip had feared games would be canceled.
“You know, so many different events have been canceled throughout our time there, and all we kept saying is … we flew all these miles to come over to China — we would love to play the game of basketball in front of the fans,” James said.
When the NBA canceled news conferences for the teams last week, the league said the players “have been placed into a complicated and unprecedented situation while abroad and we believe it would be unfair to ask them to address these matters in real time.”
After Morey’s initial comments caused a stir in China, Morey tweeted that he “did not intend my tweet to cause any offense to Rockets fans and friends of mine in China. I was merely voicing one thought, based on one interpretation, of one complicated event.”
The NBA has been hit with a backlash of its own, particularly after it released different statements about Morey’s remarks in English and Mandarin. As NPR’s Brakkton Booker reported, the mixed messages “exposed the NBA to criticism that it was attempting to appease China at the cost of traditional U.S. values — such as free speech.” The league later clarified in a news conference that it supports freedom of expression from the NBA’s community members.
The protests in Hong Kong, which have continued for months now, are calling for greater freedoms in the territory. In recent weeks, they have grown more violent, with clashes between demonstrators and police. Earlier this month, a protester was shot by police.