26 Arrests In Medicare Fraud Case

Associated Press

FORT LAUDERDALE, Fla. — Federal agents arrested 26 suspects in three states Tuesday, including a doctor and nurses, in a major crackdown on Medicare fraud totaling $61 million in separate scams.

Arrests in Miami, Brooklyn and Detroit included a Florida doctor accused of running a $40 million home health care scheme that falsely listed patients as blind diabetics so that he could bill for twice-daily nurse visits.

The U.S. Department of Justice and U.S. Department of Health and Human Services said the indicted suspects lined up bogus patients and otherwise billed Medicare for unnecessary medical equipment, physical therapy and HIV infusions.

Indictments were issued for 32 people in all, but the status of the other suspects wasn't immediately known.

Miami Dr. Fred Dweck, along with 14 people with whom he worked, was accused in an indictment of running a scam to tap a Medicare program that pays very high rates to care for the sickest patients.

Dweck referred about 1,279 Medicare beneficiaries for expensive and unnecessary home health and therapy services, bribing the owners of two Miami clinics to join the scam. He also faked medical certifications, according to the indictment.

A telephone listing for Dweck could not be found and it was unclear if he had a lawyer.

"No matter what type of fraud is committed, there is one common denominator and that denominator is greed," Assistant Attorney General Lanny Breuer said. "Medicare fraud is not a victimless crime. It hurts every American taxpayer by raising the cost of health care."

The raids come a week after a report that Miami-Dade County received more than half a billion dollars from Medicare in home health care payments intended for the sickest patients in 2008, which is more than the rest of the country combined, according to a report by the Department of Health and Human Services' Office of Inspector General. Medicare paid the county about $520 million, even though only 2 percent of those patients receiving home health care live here.

In Detroit's raids, suspects paid recruiters to find patients willing to feign symptoms to justify expensive testing, including nerve conduction studies, federal authorities said.

A mother and son were charged in Brooklyn with billing Medicare $246 per patient for expensive shoe inserts reserved for diabetes patients, even though they only provided cheap, over-the-counter versions.

Including Tuesday's arrests, a Medicare Fraud strike force formed by the Justice and Health departments has now charged suspects accused of bilking Medicare of more than $1 billion in less than two years.

The pilot strike force, which started in Miami in 2007, has indicted more than 460 suspects in Medicare fraud scams. The program is now in Los Angeles, Houston and Detroit. HHS Secretary Kathleen Sebelius also announced Tuesday the operation will expand to Tampa, Fla., Baton Rouge, La., and Brooklyn.

Cleaning up an estimated $60 billion a year in Medicare fraud will be key to President Barack Obama's proposed health care overhaul. HHS and DOJ have promised more money and manpower to fight the fraud.

Subsidies For Private Medicare Plans
On The Chopping Block
Story from the Wall Street Journal

The government late Monday is expected to set in stone the 2010 rates it will pay health insurers to run private Medicare plans. Most signs suggest that cuts are coming in the subsidies that the industry got during the Bush administration.

Stocks of health insurers were sucked into a surprise tailspin in February after Medicare officials signaled they planned an effective 5% cut in those payments after formula adjustments. Insurers, medical societies and others have had six weeks to give regulators their arguments before the payment rates become final for next year.

Their arguments, plus an effort by 17 senators from both parties who on Friday urged Medicare to reconsider the way it calculated the effective cuts, could sway the Centers for Medicare and Medicaid Services to compromise on the new payment rates, as the federal agency has in previous years. But its new management hasn't given any hint of letting up on efforts to rein in federal subsidies for the private-sector Medicare plans.

More than 10 million beneficiaries get their medical and drug coverage through so-called Medicare Advantage plans, which the Bush administration promoted with extra benefits for seniors and by providing subsidies to insurers that offer them. President Barack Obama wants to finance a good chunk of his health-care agenda by cutting those payments over time to the level of traditional Medicare's per-patient outlays. But the rates signaled in February by the new administration caught insurers -- and Wall Street -- off guard by cutting payments so soon.

The stock performance of big Medicare Advantage players on Friday suggested that many investors "don't believe it will be a positive surprise," said Matthew Borsch, analyst at Goldman Sachs. Humana Inc., already down 30% for the year, shed $1.54, or 5.7%, to $25.46 on Friday.

If the payment cuts remain or change little from those proposed, insurers may raise premiums or cost-sharing amounts, such as copayments The Blue Cross Blue Shield Association argues that the cuts could translate into premium increases or benefit reductions of between $50 and $80 a month for seniors. That could slow enrollment in a business that has been critical to many health insurers' profit growth in recent years.

Medicare Advantage wraps physician and hospital services in one. Unlike traditional Medicare, the government doesn't pay providers directly but instead pays insurance plans to manage care.

The Obama administration argues it wants to make sure the plans aren't overpaid while not providing value or better care. Last week, it took steps to tighten screws on the private plans on another front, setting new caps on what insurers can charge sick seniors and ordering them to be more upfront about what they cover.

CyberKnife Recieves Uneven Coverage from Medicare

Geography Has Role in Medicare Cancer Coverage

By STEPHANIE SAUL

Published: December 16, 2008

The medical tool’s catchy name, CyberKnife, evokes digital accuracy. But the way the federal Medicare system treats CyberKnife seems anything but precise.

CyberKnife is a new but fast-growing radiation treatment for prostate cancer, spurred by radio and newspaper ads that stress its convenience and results. The chief selling point is that CyberKnife treatments take five days instead of the eight weeks for conventional prostate cancer radiation, although many experts say they believe that the medical evidence is inconclusive on whether it works as well as those older methods.

Read Entire Article from the NY Times

More Info on Medicare Programs

This time from Florida.

Time To Change Medicare Programs

By ADON TAFT, Life to the Fullest

Hernando Today

Published: December 1, 2008

This is the annual open window period for either signing up for various Medicare programs or to switch from one to another. If you are confused about which plan you should choose, you can get advice from an impartial person trained to help you decide before Jan. 1 which plan is best for you.
The aid is provided by 400 volunteer counselors throughout the state serving with the SHINE (Serving Health Insurance Needs of Elders) program. You can get assistance by calling, toll free, the Elder Helpline at 1-800-963-5337. They will give you the time and place counseling sessions are available. If you are unable to get to any of those places at those times, your phone number will be taken and a counselor will call you to discuss Medicare eligibility, enrollment and coverage issues; health plan choices; appeal rights; Medigap (Medicare supplemental) policies; Medicare prescription drug (part D) plans; long-term care options; prescription assistance resources; or Medicaid details.
A good way to do your own research and comparison of policies is to get on the Internet and look on the official site at www.medicare.gov. Good explanations of the differences between types of policies and comparisons of their features are to be found there.
*****
More than 1.7 million Floridians (that's one of 10 residents) are caring for a frail elder, reports the state's branch of the AARP. That organization's survey found that 77 percent of adults 35 or older would prefer to receive long-term care at home rather than in a nursing home.
So Lori Parham, state director of the AARP, is bucking to change Florida's status as 41st in the nation in achieving a balance between community-based and nursing home care, where Florida spends 91 percent of Medicaid's long-term care funds.
The average cost of a nursing home stay is about $75,000 a year while care at home costs about $20 an hour.
*****
One Florida business ranked in this year's AARP top 10 list for best employers for 50-year-old or older workers. It is Lee Memorial Health System based in Fort Myers where 38 percent of the 9,204 employees are 50 or older.
Those enrolled in the company's health plan receive free generic medications for treating cardiovascular disease, diabetes and high cholesterol. They also have access to free clinics at all of the system's hospitals and, at a minimum cost, personal trainers, dietitians and nurses' supervision in a weight-loss program.
*****
Thanks to the Mortgage Forgiveness Debt Relief Act, you now have up to two years following your spouse's death to sell your jointly owned house and keep up to $500,000 in profits tax free.
Previously, a widowed homeowner had to sell the house the same year as the spouse's death to qualify for the tax break.
*****
In today's economy, 10 percent of Americans 65 years of age or older have turned for help from families or charities, according to a story by Peter Jaret in a recent edition of the AARP Bulletin. But of those eligible for food stamps, only 34.5 percent of them apply for that aid.
The same issue reported that 1.3 million Medicare beneficiaries are having trouble finding a primary care physician because of a shortage of doctors going into general practice.
Since Medicare and insurance companies establish the fees, primary care doctors are forced to take on more patients and work longer hours to generate revenue. Therefore they spend less time — as little as 15 minutes — with each one, the article quotes a spokesman for the American College of Physicians.
In addition, general practice doctors earn half or less than what many specialists earn. Consequently, only 13 percent of first-year residents in internal medicine in a recent survey indicated an intention to enter a general practice.
Adon Taft is a resident of Brooksville. If you have questions about any issue connected with aging, except medical conditions, please write to Life to the Fullest at Hernando Today, 15299 Cortez Blvd., Brooksville, Fla. 34613, or send e-mail to adontaft@yahoo.com. Please include your name and address.

The Medicare D shell game

One example of the labyrinth that is Medicare. Like it or not, we are all going to have to pay attention to the devilish details - on an annual basis.

It's a pain for seniors to pick from the myriad drug insurance programs, but it pays to do it - every year.

By Robert Strauss

For The Inquirer

Kim Andrews had just helped a woman save a couple of hundred dollars on her new Medicare drug plan.

"I asked her about her husband," said Andrews, the Delaware County coordinator for Apprise, the Pennsylvania health insurance counseling service. The woman said " 'Oh, my husband loves his plan. He won't change.' "

"Well, I checked his drugs anyway, and it turns out his plan was no longer going to cover two of his drugs," Andrews said. "I found him another plan that would save him $2,771. That's huge. People are just unaware, it seems."

Read entire 3-page report at the Philadelphia Inquirer.

Senators Compliment CMS Website - But Want More Transparency

Senators Compliment CMS on Nursing Website but Push Bi-Partisan Bill for More Info

Democrat Kohl, Republican Grassley push bill to expand transparency

April 28, 2008 – Two U.S. Senators from different parties came together last Friday to compliment the Centers for Medicare and Medicaid Services for increasing the information available on their Website, Nursing Home Compare, but they say the agency has a ways to go to achieve the transparency and information for consumers called for in the Senate bill they have crafted.

Senators Herb Kohl (D-WI) and Chuck Grassley (R-IA) complimented CMS Acting Administrator Kerry Weems for identifying on the site the most troubled nursing homes. They have been designated as Special Focus Facilities (SFF) by CMS.

Kohl and Grassley said that CMS still has a long way to go to meet the demands called for in their bipartisan bill, the Nursing Home Transparency and Improvement Act (S. 2641), which would require Nursing Home Compare to display accurate, timely information in a format that can be easily understood by consumers across the country.

“Americans should have access to as much information about a nursing home as possible," said Kohl.

Read Entire Article

Number of Presciption Drugs Covered by Medicare Dropped for 2008

Drug coverage - by number of drugs covered - from the four largest Medicare providers have been slashed by an average of 30% from 2007. AARP MedicareRx Preferred, AARP MedicareRx Saver, Humana PDP Standard, and Humana PDP Enhanced have all lowered the number of prescription drugs they will cover for seniors. In the case of AARP MedicarRx, for example, the number has dropped from 3,763 in 2007 to 2,627 different drugs covered for the current year. Of the top ten prescription drug providers, all but two have decreased the total number of covered drugs under Medicare Part D.Seniors and their care providers need to carefully review the changes in policies and their medications to avoid costly shocks at the prescription booth.

A reason for some of the drops is the Center for Medicare-Medicaid Services (CMS) decision to eliminate coverage for drugs either not approved by the FDA, or drugs approved prior to 1962 - when approval was based upon safety but not efficacy. According to CMS policy, drugs approved in the period 1938-1962 which have since been determined to be “less than effective,” should not be covered by Part D plans.

The Official U.S. Government Website for People with Medicare offers a Formulary Finder, organized by state. The Finder allows you to find plans in your state that match your required drug list:

Formulary Finder