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Feds killed 2014 plan to curb Medicare Advantage overbilling
- chomp 2y ago*killed, not kill. This happened in 2014 and came to light as a part of a current multibillion dollar DoJ lawsuit against United Healthcare.
- cool_dude85 2y agoSince 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.
- nradov 2y agoI 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.
- firesteelrain 2y agoGetting them the care is key. It’s not clear the care was provided at all.
- roenxi 2y agoMaking 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.
- ruthmarx 2y ago> 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.
- seaourfreed 2y agoThe US Gov used to put people in prison for these things. Now it is a financial law suit slap on the wrist.
- briffle 2y agoThey would still put you in jail. But when you steal billions, you get to pay a $200M fine, with no admission of wrongdoing….
- dredmorbius 2y agoProsecutors, 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.)
- dredmorbius 2y agoRight. 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".)
- epmaybe 2y agoAdvantage 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.
- dredmorbius 2y agoThe 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 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.)
- newsclues 2y agoOh so the Hope for America was fake?
- dang 2y agoI've edited the title to make that clearer. Thanks!
- readthenotes1 2y agoI 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.
- markus_zhang 2y agoOr maybe their lives or political lives, being cynical.
- rqtwteye 2y agoThe 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.
- zdragnar 2y agoThe 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.
- rafram 2y agoAnd yet insurers aggressively push people toward their Medicare Advantage plans. I doubt they’re doing that out of charity.
- murderfs 2y agoThat'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)
- cool_dude85 2y agoWild. Scam on top of a scam. Crazy that the Obama administration refused to stand up to the industry on this.
- stackskipton 2y ago>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.
- shiroiushi 2y agoYep, 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.
- firesteelrain 2y agoWhat will we be saying about a potential Harris Administration in ten years? I wonder.
- shiroiushi 2y ago"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.
- seaourfreed 2y agoThe 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.
- Modified3019 2y ago>$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?
- GauntletWizard 2y agoI would prefer that number be lower, but for how much they get it's already depressingly low.
- Modified3019 2y agoAh, yeah that’s reasonable. If we are gonna be run by whores, they may as well be expensive ones.
- bruce511 2y agoThis 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.
- tbrownaw 2y ago> 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".
- lotsofpulp 2y agoYes, 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.
- a3n 2y agoWell, 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.
- 29athrowaway 2y ago[flagged]
- ruthmarx 2y agoThis doesn't matter. Not while the US is the reserve currency, and not for a few other reasons either. It's a fake GOP campaign point and nothing more.
- UberFly 2y ago[flagged]
- Propelloni 2y agoIt is entertaining to me that the GOP is actually the party working hardest to end the US$ status as the reserve currency. I don't know if they just like self-fullfilling prophecies or if they really have no grasp of network effects. Probably both.
- ljsprague 2y agoObviously it doesn't matter until it suddenly does.
- refurb 2y agoTo be honest it sounds like the government case might be falling apart.
- mikequinlan 2y agoThis 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…
- dredmorbius 2y ago<https://news.ycombinator.com/item?id=41430804 https://news.ycombinator.com/item?id=41430804>
- deleted 2y ago[deleted]
- SECProto 2y agoThe 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)"
- dredmorbius 2y agoSee earlier thread: <https://news.ycombinator.com/item?id=41430804 https://news.ycombinator.com/item?id=41430804>
- kwhitefoot 2y agoIs 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?
- ruthmarx 2y ago> 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.
- p_l 2y agoFriedman'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
- justinclift 2y agoFor reference: https://en.wikipedia.org/wiki/Friedman_doctrine https://en.wikipedia.org/wiki/Friedman_doctrine
- atoav 2y agoWell I am pretty sure there are those news. They are just more and more limited to small companies.
- archagon 2y agoI 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 https://en.m.wikipedia.org/wiki/List_of_benefit_corporations) and B Corps (https://sustainabilitymag.com/articles/top-10-b-corps https://sustainabilitymag.com/articles/top-10-b-corps).
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- deleted 2y ago[deleted]
- martin293 2y ago(2014)
- dredmorbius 2y agoNo. 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.
- firesteelrain 2y agoThis 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.
- oldpersonintx 2y ago[dead]
- FollowingTheDao 2y agoI 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.
- BoredPositron 2y agoNeeds a (2014)...
- dredmorbius 2y agoNo it does not: <https://news.ycombinator.com/item?id=41433084 https://news.ycombinator.com/item?id=41433084>
- deleted 2y ago[deleted]
- dredmorbius 2y agoI 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.
- deleted 2y ago[deleted]