Feds killed 2014 plan to curb Medicare Advantage overbilling | Hacker News Reader

Feds killed 2014 plan to curb Medicare Advantage overbilling

kffhealthnews.org

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*killed, not kill. This happened in 2014 and came to light as a part of a current multibillion dollar DoJ lawsuit against United Healthcare.

Since you seem to be clued in on this - what is United's defense here other than to muddy the waters? It seems from the article that they must sign an affidavit, or otherwise formally state, that the codes are valid to their best knowledge. But they do all these reviews that show some of the codes aren't valid, but they still bill for them. Seems pretty cut and dried.

I won't say anything specific about UnitedHealthcare or take a position on their actions but will comment generally about Medicare Advantage plans. The standard defense is that many of the diagnosis codes are highly subjective and depend on clinician judgment more than objective lab tests. Different doctors might reach different conclusions but that's normal in medicine and doesn't necessarily indicate fraud or malpractice. Health plans will also claim that adding formal diagnosis codes for all of a patient's conditions to their chart helps to get them the best care.

Getting them the care is key. It’s not clear the care was provided at all.

Making some guesses, but probably by spinning the plan the way it was presented in the first two paragraphs of the article.

There is a system for when one party wrongs another - the wronged party takes them to court and justifies why there should be redress. The idea at the start of the article seems to be that the government seems to want to override that with some other process the seems to involve people dobbing each other in or employees looking for opportunities to send their employers money to, effectively, the tax office. I'd be furious if someone tried to involve me in such a system. I don't want to be dealing with people who are looking for opportunities to get me in trouble or vice versa.

> I'd be furious if someone tried to involve me in such a system. I don't want to be dealing with people who are looking for opportunities to get me in trouble or vice versa.

If the things people are trying to catch people for are immoral and massively harmful, then everyone moral should willing want to participate in such a system.

The US Gov used to put people in prison for these things. Now it is a financial law suit slap on the wrist.

They would still put you in jail. But when you steal billions, you get to pay a $200M fine, with no admission of wrongdoing….

Prosecutors, as with all predator classes, choose their targets carefully so as not to both expend unrewarding effort and avoid self-injury.

Unfortunately, this means often foregoing large and egregious targets, such as the organised criminal syndicate known as United Healthcare, in favour of far smaller, and more tractable, targets. This has always been the case, and is hardly limited to the United States.

Finding ways to remedy this fundamental systemic dysfunction would be greatly appreciated.

(The observation in my first 'graph isn't a sneer or slight at prosecutors, though some of those might also be deserved. It's a recognition of the nature of the activity.)

Right. The headline was edited to fit HN length limits with the unfortunate effect of making a decade-old action appear to be current. I'd suggest dropping "Advantage" which reduces specificity but doesn't mislead to the same extent.

My own practice is to note headline edits in a submission comment, whether for length, clarity, removing clickbait / outrage, etc.

And the fact that the past nature of the event is immediately clear in the first 'graph of TFA strongly encourages the act of R'ing TFA, rather than reacting blindly to headlines.

(I've emailed mods suggesting an improved title of: "Feds Killed Plan to Curb Medicare Overbilling After Industry Opposition in 2014".)

Advantage is relevant. Medicare advantage is a specific type of plan that isn’t quite Medicare that insurance companies offer. And it’s at the center of that case.

The question isn't what is relevant, the question is comparative relevance. "Medicare plan" might be another option, though my suggestion to add the year already comes up hard against HN's 80-char limit.

Wordsmithing titles is in fact both hard and a matter of compromises.

HN's guidance is to use the original title, except where that's misleading or clickbait, and as an alternative to shorten that, or to substitute alternate text from either a subhead / alternate headline, or the article itself:

<https://news.ycombinator.com/item?id=29899854>

If you care to suggest something that is accurate, covers the relevant elements, and fits inside 80 characters, you're welcome to do so. It makes the mods' decision and action far easier, and is why I'd made a specific recommendation myself. I'm not wedded to that, but it is my good faith best-effort attempt. I'm happy to consider better. I've scoured the article a few times with limited success myself.

Though "DoJ alleges United Healthcare cheated Medicare out of more than $2 billion" (from "Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion") might also work, and makes the titled action current. 74 characters.

(I've submitted that as an alternate to HN's overworked mods as well.)

Oh so the Hope for America was fake?

I've edited the title to make that clearer. Thanks!

I cannot think of a better argument for a DoJ antitrust remedy seeking break-up and/or dissolution of the organised criminal syndicate otherwise known as United Healthcare.

Hopefully that's in the offing given:

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.

(From TFA.)

Kudos to the DoJ for the current case. I do hope they prevail and secure meaningful consequence.

Is there anyone left in any large American corporation with any virtue? The endless stream of news about corporations behaving badly lends credence to the idea that the US is purely a dog eat dog society.

But surely it can't really be true?

Could we have some kind of counter-news that celebrates the corporations that do things right, that encourage their employees to behave as upstanding members of society?

> But surely it can't really be true?

Sure it is. Any company that isn't evil if they get big enough will become evil, just like Google who removed 'don't be evil ' as a slogan when they got large enough.

You can thank Reagan and gutting company regulation for this.

Friedman's Doctrine had been taught in Business Ethics classes for so long that people will honestly tell you it's part of the law.

That's not an environment that makes for a good behaviour to general society

For reference: https://en.wikipedia.org/wiki/Friedman_doctrine

Well I am pretty sure there are those news. They are just more and more limited to small companies.

I think the virtue has to be part of a corporation’s founding principles. See benefit corporations (https://en.m.wikipedia.org/wiki/List_of_benefit_corporations) and B Corps (https://sustainabilitymag.com/articles/top-10-b-corps).

There was a quip from Admiral Hopper's video posted here last week[1] which caught my ear:

You manage things. You lead people.

Leadership is a forgotten and/or underappreciated concept. And Hopper was speaking in 1982.

I can of course think of some counterarguments, and Hopper makes a few of them herself, consciously or not, in distinguishing rote, gut, and/or traditional modes of management from those based on measurement and outcomes. But she also clearly describes what she means, and practiced, by "leadership" as well. Especially as regards principles.

________________________________

Notes:

1. <https://news.ycombinator.com/item?id=41356528> The referenced comments occur late in the 2nd video of the set.

Well, of course. They wouldn't be able to research and implement innovative excess billing without excess billing.

Your overpayment today funds your children's and grandchildren's more effective overpayments.

It's your legacy.

Yes, R&D into exploitation must proceed. I do not know how these health insurance companies survive on a gross margin of only $2000 per person[1]!

[1] https://www.kff.org/medicare/issue-brief/health-insurer-fina...

The top comment on this topic really exposes the HN userbase and what it has become.

<https://news.ycombinator.com/item?id=24313136>

Vote, flag, or vouch as you see appropriate instead.

The best way to improve thread quality is that, and leading by example as I've attempted with a top-level comment here.

Yes, and it's great!

But seriously, do you want your mind to live in a monoculture or do you want it to be challenged and open to new idea?

What is this? The argument for censorship in opposite world?

> Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

Sounds like the "what" is already properly illegal without needing to dictate the "how".

Yes, the root problem is CMS effectively audits managed care organizations (MCO, or health insurance companies) far too rarely. And even when they do audit them, they audit far too few and with insufficient depth such that people working inside the MCO have no justification to spend more resources on ensuring the job is done properly.

If CMS was constantly auditing random cases, then the MCOs would have to tighten up operations. As it is, any MCO that does will lose out to any MCO that plays it fast and loose, since MCO profit margins are low single digit percentages.

Although, I am sure one can kick up the problem to legislators not allocating enough funding to CMS to constantly audit MCOs, just like the IRS does not have enough funding to audit sufficient taxpayers.

The USA is a Kleptocracy since US congress members sell-out for lobbyists and money-in-politics. $3.5 billion per year flow through lobbyists, and that is all it takes to corrupt our congress.

>$3.5 billion per year flow through lobbyists, and that is all it takes to corrupt our congress.

I can’t tell what you would consider an improvement, that number being higher or lower?

I would prefer that number be lower, but for how much they get it's already depressingly low.

Ah, yeah that’s reasonable. If we are gonna be run by whores, they may as well be expensive ones.

This misses the point somewhat.

The 3.5 billion doesn't go to congress people. It goes into reelection coffers. Or as the sibling points out into electing-others-coffers.

We like to believe in free-and-fair elections, but in most cases the options are "unknown names". Most people vote party, not person.

The real "electing" happens at the primary level even all candidates are the same party. At this level money talks (through advertising.) Basically its a most-money-wins setup.

Congress is the pinicle of the iceberg you can see, but the real action happens at state level, in primaries, etc. That's why you end up with "2 bad choices" come election time.

The only way to remove money from politics is to ban TV and internet political advertising. (And it won't shock you to discover TV and internet think that's a bad idea.) Frankly, I'm not even sure that would help.

Politics bows to moneyed interests because politics is built on access to advertising money. RFK didn't drop out because he lost interest, he dropped out cause he ran out of money. He then sold his endorsement to the highest bidder.

Ultimately US society values money above all else. So it's not surprising that money is at the root of US politics. As far as the system is concerned this is not a bug, it's the killer feature.

An improvement would be if the number was lower because hired lobbyists were less effective. We should undo Citizens United with legislation so that concentrated wealth can't be used to bully politicians as easily, giving them the freedom to act on voters needs. If we treat unlimited political spending as the corruptive force it is instead of a fundamental right, things wouldn't be perfect but they would surely be better. Sadly, a corrupt legislature is unlikely to legislate away corruption. Campaigning on reversal of the CU ruling brought massive popular support and individual donations to Bernie Sanders' presidential campaign, but IMO was a also a big (maybe biggest) reason he was treated as untenable by the establishment.

Imagine it another way. I am a health care company, you are a congressperson. You want to vote for something I don't like. I visit your office and tell you I am thinking about spending 20 million dollars in dark money ads to help elect your opponent who agrees with my position. As the politician can you even vote for this bill knowing it will probably end up with non-stop negative attach ads against you and your loosing your seat, your ability to vote on other important legislation. You vote for the bill anyway, it looses. The attack ads start, they are lies but they are continuous and overwhelming. You loose your seat to someone who will do what the lobbyist/industry wants. You are now on the outside.

In a just society this would be considered extortion

Any solid example of something like this happening?

AIPAC

What other way is there to imagine it?

You just described how it is a systemic issue. It’s not a case of bad apples but the system itself.

Your true hypothetical is even more damning.

And as with most big structural issues in the US, the answer is right there and obvious for everyone wanting to look for it: severely restrict campaign spending, ban PACs and the like, and boom, the election process and government in general will become much less beholden to money interests.

(Yes, I know about Citizens United - it has to be repealed, which is of course possible).

First of all $3.5 billion is not a lot of money when you consider that it represents all industry. We spend significantly more money on almonds [1]. More importantly, lobbying is literally just talking to politicians, and the vast majority of this money is just spent on salaries and expenses for professionals who do so.

The reason it seems like congress is so beholden to corporate lobbyists is because corporations are the only ones who take lobbying seriously these days. Grassroots lobbying being taken seriously is what lead to the passage of the Civil Rights and Clean Air acts. Even today, there are examples of grassroots lobbying that prevails over corporate interests. A handful of nimby can perpetually stall billions of dollars of real estate development, and there is no way billionaires like Peter Thiel are happy that abortion bans have cost the Republican Party so much political capital.

[1] https://slatestarcodex.com/2019/09/18/too-much-dark-money-in...

I wonder if the people afraid of industry pressure were hoping to get a job in the industry at a later point?

Not sure why they would care, otherwise.

Or maybe their lives or political lives, being cynical.

The politicians and political appointees on top of the agencies need to keep the sweet lobby money flowing and they are also probably scared of an ad blitz by the industry against them. Once you have enough money (like many Super PACs), you don't even need to deploy the money. The threat alone is enough.

The less cynical answer is that the insurers would simply stop offering Medicare advantage plans at all, and the people who run the programs don't want to be responsible for the mess.

Passing the buck is basically in the job description for a lot of government work, especially but not limited to elected positions.

And yet insurers aggressively push people toward their Medicare Advantage plans. I doubt they’re doing that out of charity.

That's not that surprising because the margins on insurance plans aren't all that high. The percentage of each dollar of premium how much insurance companies have to spend on medical care (aka "loss ratio") is mandated to be at least 85%. Relatively small percentage changes in the premium they bring in can make them go from being the most profitable plans they have to not being worth having at all.

(This is generally true across the insurance industry: you can see other examples of companies pulling out because of relatively small changes with home insurance companies leaving California and Washington)

This sounds just like lack of IRS enforcement. CMS audits too few of times and the system isn’t setup to identify upcoding that causes overpayments.

Medical coding itself is already too complicated to make it easy to distinguish from those codes meant to increase payments and those that are legitimate payments.

I was furious when Medicare Advantage came out because I saw it as the first step of privatizing Medicare in the U.S. which forced millions of people into contracts with private health companies. It was then I was done with the Neoliberal Democrats.

I am on permanent disability and in the last three years there has been constant pressure for me to sign up and I always refuse. They want to switch me to more expensive meds when the generics work fine.

Medicare Advantage is just another transfer of wealth to the top.

Needs a (2014)...

No it does not: <https://news.ycombinator.com/item?id=41433084>

(2014)

No.

The decision occurred in 2014.

The story is current, released last week.

HN's policy is to highlight non-current stories, not current stories of non-current events.

There's an active discusssion of improved titles which would make clearer both current actions and the historicity of the previous retreat of regulators.

This is a current (2024) article with new information about events that occurred 10 years ago, in 2014.

>…But in May 2014, CMS dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry…

<https://news.ycombinator.com/item?id=41430804>

The use of title case in this headline makes it incomprehensible to me as a non-American (along with the fact that this happened a decade ago). A corrected title might read:

> "Feds killed plan to curb Medicare Advantage overbilling after Industry opposition (2014)"

See earlier thread: <https://news.ycombinator.com/item?id=41430804>

To be honest it sounds like the government case might be falling apart.

Wild. Scam on top of a scam. Crazy that the Obama administration refused to stand up to the industry on this.

>Crazy that the Obama administration refused to stand up to the industry on this.

Not really, if you look at Obama Presidency, he was extremely neoliberal. Bank bailouts, healthcare bill and massive corporate consolidation.

Yep, the "hope and change" stuff was just a slogan to get votes. Even though Obama himself seemed like a political outsider at the time, his presidency was just more of the same, basically a continuation of the Clinton era.

What will we be saying about a potential Harris Administration in ten years? I wonder.

"Better than the alternative."

I'm not sure many people have any huge hopes for Harris, aside from it being nice to finally have a female chief executive (an achievement most other peer nations made long ago; even Pakistan had a female PM). When Obama was elected, the US had gone through 2 terms of GWB's terrible policies and the two wars he started (1 somewhat justified, 1 complete BS, both handled extremely poorly after the initial military victory). Obama was running against McCain/Palin, with McCain being a pretty reasonable Republican and decent person, and very unlikely to start any stupid new wars, but with a complete airhead running mate who thought Africa was a single country. It wouldn't have been a total disaster if McCain won, as long as he didn't die in office.

This time around, the country has already seen what 1 Trump term results in, and it's really bad. A second term will be a disaster, probably even worse than the 1st one. Anyone with half a brain might not be super excited about Kamala, but she appears to be sane and reasonably competent, and when compared to the alternative, that's really good enough.

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