Insurance giant Humana Inc., which operates some of the nation’s largest private Medicare health plans, knew for years of billing fraud at some South Florida clinics, but did little to curb the practice even though it could harm patients, a doctor alleges in a newly unsealed whistleblower lawsuit.

The suit was filed by South Florida physician Mario M. Baez. It accuses Humana, and his former business partner, Dr. Isaac K. Thompson, of engaging in a lucrative billing fraud scheme that lasted for years. The suit also names three other Palm Beach County doctors, two medical clinics and a doctors’ practice group as defendants. The suit was filed in October 2012, but remained under a federal court seal until Feb. 26.

Humana had no comment. “As a matter of long-standing company policy, Humana does not comment on pending litigation,” said company spokesman Tom Noland.

Thompson, a Delray Beach doctor, was indicted early last year on health care fraud charges stemming from similar allegations. He had pleaded not guilty, but last week indicated he would change his plea, and was to appear in federal court in Fort Lauderdale Friday, according to court records.

The Baez case is likely to bring fresh scrutiny to the giant Louisville, Ky.-based insurer, which covers more than 3 million elderly patients in its Medicare Advantage plans nationwide. The case could also spotlight costly flaws in the government’s complex and controversial method for paying private Medicare health plans.

The Baez suit targets a billing formula called a risk score, which is designed to pay Medicare health plans higher rates for sicker patients and less for people in good health. But overspending tied to inflated risk scores has cost taxpayers tens of billions of dollars in recent years, as the Center for Public Integrity reported in a series of articles published in 2014.

Federal officials have struggled for years to stamp out these overcharges, known in health care circles as “upcoding,” while at least a half-dozen whistleblowers have filed lawsuits accusing Medicare Advantage plans of ripping off the government.

Baez’s case adds a new wrinkle because it alleges that inflating risks scores not only wastes taxpayer dollars, but can also cause a patient to be harmed by improper medical treatment.

Baez said in a letter to the presiding judge in the case, U.S. District Judge Kenneth A. Marra, that treating elderly patients with “multiple ailments” is difficult when you have accurate data, but “when medical records are poisoned with misleading data [from inflated risk scores] it becomes Russian roulette.” Patients aren’t told their risk score and aren’t likely to know if a doctor has exaggerated how sick they are or added bogus medical conditions to their medical records to boost profits, Baez said.

Baez and Thompson were partners in two clinics in Humana’s network, Lake Worth Medical, P.A. and IM Medical P.A., in Delray Beach, from 2003 to 2012. Baez alleges in his suit that in February 2009 he became suspicious of billing practices at the two clinics and confronted doctors who worked there about it.

The doctors said they had been told by Thompson to “upcode” diagnoses, according to the suit. Baez said he reported the abuses to Humana in May 2009, but the company failed to return the alleged overpayments. In 2012, Baez contacted the FBI, which eventually sparked the Department of Justice criminal investigation that ensnared Thompson.

Doctors use a series of billing codes to document patients’ health, including any diseases they have and how severe they are. The Medicare Advantage plans report these codes to the government, which calculates a patient risk score and sends off a payment to the health plan.

In Thompson’s case, Humana paid 80 percent of the money it received to the doctor and retained the rest. Prosecutors charged that fraudulent diagnoses submitted by Thompson between January 2006 and June 2013 generated overpayments of $4.8 million.

Baez alleges that Humana encouraged overbilling by providing doctors in its network with forms that highlighted “more profitable” diagnosis codes they could use for patients. Many were statistically impossible to support, according to the suit, which cited allegedly inflated risk scores in more than three dozen patients.

For instance, scores of patients at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only one in 1,000 people truly had this disorder, according to Baez.

Similarly, aging patients with ordinary joint aches were diagnosed with “unspecified inflammatory polyarthropathy,” a chronic disease that requires the care of a specialist, according to the complaint.

Others with minor depression were said to have bipolar disorder, which paid the health plan a higher rate. According to the complaint, Humana officials agreed to fully correct the overages, but later “reneged” on the promise to do so and failed to correct the record with Medicare, according to Baez. The health plans are required to attest to the accuracy of any diagnoses submitted to the government.

The other doctors named as defendants in the Baez suit are Dennis Salazar, Arnaldo Mora and Daniela Mayer. All formerly worked for Thompson. The suit also named MCCI Group Holdings, a medical practice group. None of the doctors could be reached for comment. MCCI Group had no comment.

Humana has previously acknowledged it has been the target of investigations into its billing practices, including some involving whistleblowers. So has another large Medicare Advantage plan operated by UnitedHealth Group. Last month, UnitedHealth said it was cooperating with a Department of Justice review of its billing practices, according to a Securities and Exchange Commission filing.

Court filings unsealed in the Baez case confirm that the company faces several similar whistleblower suits, including at least one that remains under court seal. The court records also suggest that the criminal fraud investigation that snared Thompson is not over.

“There are some components of the criminal investigation which remain active,” Assistant U.S. Attorney Mark A. Lavine wrote in a December 2015 court filing. Lavine added that the investigation “continues to move forward aggressively.”

Lavine also indicated that two other whistleblower cases have been filed against Humana “in connection with similar allegations at other clinics.”

Baez told the Center he has been frustrated with the plodding pace of the government investigations into Medicare Advantage. Keeping the matter under seal for so long “protects those who have perpetrated the fraud, but keeps patients and the public in the dark.”

In November 2015, Baez wrote to Marra asking that the seal be lifted.

“Seven years ago I presented to Humana the problem with upcoding and entering false information in patients’ medical records in order to justify the upcoding… Nothing has changed. Nothing has been done to protect the hundreds of patients with misleading medical information in their medical records,” Baez wrote.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter. Follow Fred Schulte: @FredSchulte.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

The fate of the controversial Texas abortion law is in the hands of the Supreme Court, and a decision isn’t expected before June. But how this particular law reached the high court and how its opponents have gathered evidence to strike it down represent fresh twists in an acrimonious national debate stretching back to the 1970s.

Many of the provisions of the 2013 Texas law, known as HB 2, are based on model laws created by Americans United for Life, a group that opposes abortion rights and that has worked for years to get a carefully crafted state bill on health and safety provisions surrounding abortion before the Supreme Court. On the other side, abortion-rights forces have been fighting the law with data from university-based research on how the law is affecting women’s access to abortion services.

The court is looking at two provisions of the law. One requires doctors who perform abortions to have admitting privileges at a hospital no more than 30 miles from clinics that provide abortion services. The other requires the clinics to meet the same standards as ambulatory surgical centers that perform more complicated procedures than the typical first-trimester abortion.

Clarke Forsythe, senior counsel for Americans United for Life, said the group’s most recent focus on health and safety provisions for abortion clinics was spurred by several events. One was the case of Kermit Gosnell, a Philadelphia doctor who was convicted in 2013 of murder in the deaths of three babies and one woman in his unregulated abortion clinic. Forsythe said that “was an alert to public health officials in states to upgrade their standards.”

The other was the Supreme Court’s 2007 decision in Gonzales v. Carhart, which upheld a ban on a specific abortion procedure used late in pregnancy. While that decision upheld a federal law, said Forsythe, it also “leaves more deference to the states to protect maternal health.”

The Texas case, said Forsythe, “gives the Supreme Court the first opportunity since Roe v. Wade to uphold health and safety regulations in the first trimester (of pregnancy), when 90 percent (of abortions) are done.”

But opponents of the law are working hard to make sure that doesn’t happen. Researchers for the Texas Policy Evaluation Project, which is sponsored by the University of Texas-Austin and known as TxPEP, have been studying the impact of tightening of reproductive health services in Texas since before the state’s abortion law was enacted.

The project formally began after the Texas Legislature cut the budget for family planning by two-thirds in 2011. But research on the issue had begun even before that by Daniel Grossman, an OB-GYN and reproductive health researcher from the University of California, San Francisco. He was in Texas at the time and was studying women living near the Mexican border who had trouble getting reproductive health services and were traveling to Mexico for care instead. “It was not just for (birth control) pills, but for Pap smears and sterilizations and that sort of thing,” he said.

The Legislature’s funding cuts prompted interest in expanding Grossman’s study and looking at the issue around the state. “We were just really concerned that people we knew well in the El Paso area, that they were already struggling to meet their reproductive health needs,” he said.

When the Legislature passed the abortion bill two years later, he said, “we were already on the ground and had developed relationships with the abortion providers” in the state. “We really had a sense of all the different ways this was going to play out, so we were able to respond pretty quickly.”

That fast turnaround made the research project a novel one. “Usually researchers rely on state statistics to look at the impact of these kinds of policies,” Grossman said. “But there’s such a delay in getting those kinds of statistics.”

Having a head start on the research and access to their own data has allowed the project to release analyses even as the fight was going forward in the courts. For example, researchers were able to document the decline in the number of doctors performing abortions since the law was enacted; the increase in wait times for women seeking abortions; and insights into how women seeking abortions were affected by the various obstacles put in their path by the law, such as mandatory ultrasounds and waiting periods.

And while Grossman didn’t speak at the Supreme Court arguments, U.S. Solicitor General Donald Verrilli cited his work, as did the attorneys on both sides of the case, along with Chief Justice John Roberts and Associate Justice Stephen Breyer.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

Download

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

Download

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

Republican front-runner Donald Trump released a seven-point plan to change the country’s health care system that includes several familiar GOP proposals and one that puts him in agreement with, believe it or not, Democratic hopeful Bernie Sanders.

Right off the bat, Trump calls for the elimination of the Affordable Care Act, ringing the repeal bell that has been popular among a wide swath of Republicans and that has fueled dozens of votes to overturn Obamacare in Congress, including another failed attempt when lawmakers reconvened first thing in January.

The prime target is the individual mandate, the requirement that almost every American have or buy health insurance — or pay a penalty. “No person should be required to buy insurance unless he or she wants to,” the Trump proposal declares.

Obamacare relies on the mandate to make sure it isn’t just the sick and people at high risk of getting sick who buy coverage, driving up insurance costs.

While Trump decries the mandate, the idea has Republican roots. The mandate was seen as a market-friendly alternative to a national health system or a strict requirement on employers to provide coverage.

Still, the mandate and its associated tax penalties for people who don’t comply has become a lightning rod for people dissatisfied with the Affordable Care Act. In 2014, the first year that the fine for lack of coverage was in place, about 7.5 million Americans paid an average penalty of $200 for not having insurance according to the IRS. In 2015, the potential penalties rose to greater of 2 percent of annual income or $325 per adult. And this year they rise again to the greater of 2.5 percent of income or $695 per adult.

In a second plank, Trump calls for the sale of health insurance plans across state lines to bolster competition by increasing the number of policies being sold. Health insurance is regulated largely at the state level. And critics of the multistate approach, a favorite of the GOP for years, say it would erode consumer protections.

Trump hedges his call for multistate plans by saying they would have to comply with regulations in each state where they are offered. It’s hard to see how, if states continue to regulate insurance differently, the theoretical benefits he touts could be achieved in practice. In fact, over the years six states, including Georgia, enacted laws to encourage insurance sales across their borders and a Georgetown University analysis found that they failed to attract new plans into their markets.

Some Trump proposals would change the tax treatment of health coverage.

One would let individuals who buy insurance deduct its cost, as employers do for coverage they make available to workers. Many health economists argue that the opposite tack — eliminating the employer deduction — would be more beneficial. The employer tax break obscures the cost of health coverage and thereby contributes to health cost inflation. The benefits from the break also tends to accrue to more highly paid people. Under Obamacare, people with low-to-moderate incomes can get a tax credit to help defray the cost of insurance purchased on marketplaces.

The second proposal argues in favor of letting individuals take advantage of Health Savings Accounts, or HSAs. But that’s something that is already possible, and the accounts are quite popular. Right now, those accounts are tied to high-deductible health plans.

“Is Trump calling for every American to have access to an HSA, not just those in high-deductible health plans (HDHPs)?” asks a post on Forbes.com by Ryan Ellis, an adviser on tax policy for the Conservative Reform Network. “That would seem to be undermined by his statement about how young people should want to enroll in high-deductible plans–why mention them at all?”

Then there’s the chicken-in-every-pot plank that would require providers of health care to disclose prices. “Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure,” the Trump proposal says. Not many people disagree with the intent. But it’s difficult to pull off in a way that helps the average person shop. Health care prices are negotiated between insurers and providers, and people’s coverage and copays vary depending on their networks and insurance particulars.

Trump also argues for a change in financing Medicaid, the joint federal and state health insurance program for the poor and disabled. His plan calls for block grants, or lump-sum payments, to the states that they could spend as they wish. The idea has been popular with Republicans going back to President Reagan, has been revived more recently by GOP governors as a way to cut costs and has been part of Republican proposals to repeal and replace Obamacare. Critics say block grants would reduce the number of people covered by Medicaid and by shifting responsibilities to the states would ultimately saddle them with greater financial burdens.

Finally, Trump throws his support behind the importation of drugs to cut costs. “Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers,” the proposal says. This is the one where Trump and Sanders have common ground. Sanders supports the importation of drugs from Canada and his website boasts about a 1999 bus trip that took a bunch of Americans up north to get better deals.

The Food and Drug Administration, under both Republican and Democratic presidents, has opposed drug importation on safety grounds. And drugmakers restricted supplies of medicines going to drug distributors in Canada to combat a rise in online pharmacy sales to Americans more than a decade ago.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

The Supreme Court Wednesday heard what could be its most consequential abortion case in a generation. Hundreds of protestors crowded the steps of the building while arguments took place inside.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

The shorthanded Supreme Court on Wednesday heard oral arguments in what may be the most significant abortion case it has heard in two decades. The case tests whether a Texas law setting certain requirements for clinics that provide abortion places an undue burden on women seeking an abortion.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

Download

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

On Wednesday, the Supreme Court will hear what is being called the most significant abortion case in decades. In an effort to sway the justices, namely Justice Anthony Kennedy, women are sharing their personal experiences with abortion in briefs to the court. Among them is Ohio State legislator Teresa Fedor. She speaks with NPR’s Audie Cornish about why she’s telling her story now.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.

A Boston nonprofit plans to soon test a new way of addressing the city’s heroin epidemic. The idea is simple. Along a stretch of road that has come to be called Boston’s “Methadone Mile,” the program will open a room in March with a nurse, some soft chairs and basic life-saving equipment — a place where heroin users can ride out their high, under medical supervision.

Dr. Jessie Gaeta, chief medical officer at the Boston Health Care for the Homeless Program, which initiated the project, walks the avenue several times a day on her way to and from work. The path takes her past the city’s needle exchange program and a methadone clinic, as well as past one of the city’s busiest emergency rooms at Boston Medical Center.

“There are people — just in the few blocks around our building and hospital — that we’re watching overdose on our way from the parking lot,” Gaeta says.

Addiction treatment providers in the area have had hushed conversations for many months about creating a safe place where heroin users could get high. At least eight countries around the world have some sort of supervised injection facilities, monitored by nurses, where patients can both use drugs, and rest or sleep off the effects.

With state statistics now indicating that roughly four Massachusetts residents every day die from an overdose, the need for some sort of new approach seems more urgent than ever, Gaeta says. Still, her organization plans only a limited version of the sort of “safe place” other countries offer. In Boston, patients will not be allowed to take drugs in the room.

“It’s not a place where people would be injecting,” Gaeta says. “But, it’s a place where people would come if they’re high and they need a safe place to be that’s not a street corner, and not a bathroom by themselves, where they’re at high risk of dying if they do overdose.”

All the funding isn’t yet secured, she says, but the plan is to convert a conference room for this purpose. A nurse and outreach worker would move among 10 or so users to check breathing, other vitals and general health. If patients in the room need more than nursing care, there’s a hospital right across the street.

Gaeta says staff in the room will, “try like heck,” to get patients coming off a high into treatment.

Ray Tamasi, the CEO at Gosnold, an addiction treatment network on Cape Cod, says his staff tried a similar approach with alcohol addiction about 15 years ago.

It was marginally successful, Tamasi says, “but it was taxing, very labor intensive and difficult. You have to have the resources to be able to do it.”

Organizers of this “safe place” say they are are desperate to try something new. Overdoses have become the leading cause of death among Boston’s homeless men and women. But will users who inject drugs or take a cocktail of pills find their way to this room?

“I could say, for myself, I would use it, just to be safe,” says Nicole, who currently is getting treatment with methadone for her heroin addiction. She asked that we only use her first name, because some family members don’t know about her heroin use.

“A lot of addicts are homeless or by themselves,” Nicole says. “So, to have somebody — especially a nurse — keep an eye on you, and have a place to go when you’re under the influence or high … and somebody monitors you … that’s an awesome idea.”

A scientific review in 2014 of 75 research articles found that supervised injection facilities — the type of “safe room” offered outside the United States — reduced the rate of overdose. And a 2008 study found that patients in Vancouver, British Columbia and Sydney, Australia, who were monitored by a nurse while they used heroin were more likely to end up in treatment than patients who were not monitored.

The use — or lack of use — of these safe rooms in various countries highlights a divide in addiction treatment, says Dr. Barbara Herbert, president of the Massachusetts chapter of the American Society of Addiction Medicine.

“The controversy,” Herbert says, “is, does it encourage people to keep using if we make their lives less dangerous and less miserable, or can we scare people into care?”

Herbert says many health care providers in the field of addiction medicine have moved away from the “tough love/abstinence-or-nothing” approach and instead now favor options like the “safe use room.”

“It’s not that we don’t want people to be drug free,” Herbert says. “But dead people don’t recover.”

The safe use room is part of what’s known in the world of addiction treatment as “harm reduction.” The approach includes needle exchange programs so that users don’t spread infections, training in the use of naloxone, the opioid reversal drug, and more education about the dangers of opioid prescriptions and use. Some addiction experts say Massachusetts must focus more on reducing the dangers of drug use and stop expecting users to just stop.

“We’re having problems reducing people’s involvement with drugs,” says Vaughn Rees, an addiction expert at the Harvard School of Public Health. “Short of being able to implement treatment, we need to think about how we can reduce the risk of drug use.”

The idea is still widely controversial among both elected leaders and those in public health. But Charlie Baker, the state’s Republican governor, says he’s open to hearing what Boston Health Care for the Homeless has planned.

“I have tremendous faith in them,” Baker says, “and think because they are on the ground and because they are closer, most of the time, than practically anybody else who’s working with the homeless population, they tend to be a pretty good bellwether about good ideas.”

And Boston Mayor Marty Walsh, who speaks openly about his own past alcohol addiction and his recovery, says creating a space that’s supervised in this way could be an effective method of bringing heroin users into short-term care.

“I’m up for trying anything when it comes to addiction and active using,” Walsh says. “If we can help some folks — homeless folks in particular — we should try anything.”

Boston police say they have no concerns about the program’s “safe room” as planned. They would not support allowing injections inside.

“We can’t allow the illicit distribution or sale or transfer of narcotics to be happening and not take action against that,” says Lt. Det. Michael McCarthy, a spokesman for Boston’s police department.

Some in the addiction community say a room where heroin users who are high would get care, not criticism, is another sign that attitudes about addiction are shifting.

“I think we’ve come a long way,” says Joanne Peterson, who started a parent support network in Massachusetts called, Learn to Cope. “There’s a lot more talk and a lot more compassion and understanding because there’s been so many deaths. This is an enormous epidemic.”

In just the past month, EMTs revived six people after an overdose in the neighborhood where Boston Health Care for the Homeless plans to open its safe use space for heroin users.

This story is part of NPR’s reporting partnership with WBUR and Kaiser Health News.

This entry passed through the Full-Text RSS service – if this is your content and you’re reading it on someone else’s site, please read the FAQ at fivefilters.org/content-only/faq.php#publishers.