consultants are sandburs

Wednesday, May 17, 2017

The former high placed insider, he knows, he tells. An NYT image caption, "Benjamin Poehling, a former finance director for UnitedHealthcare Medicare and Retirement, in Minneapolis. 'They’ve set up a perfect scheme here,' 'he said of insurers. 'It was rigged so there was no way they could lose.' "

And when following the money, a former CFO as a whistleblower is not too bad as an informed instigator of litigation. First, an image of the company headquarters in Minnetonka, MN, published online in the highest circulation statewide daily, Strib, in its locally written item from yesterday, "Feds sue UnitedHealth alleging at least $1 billion in false claims - The government's complaint comes in a whistleblower case brought by a former employee in Minnesota." That online item is by Christopher Snowbeck, a staff writer specializing in healthcare coverage.

UnitedHealth headquarters. Imagining the sphere on the lawn art as the world,
there is the protuberance below, from the body of the sculpture

That locally written item, in short, notes:

The federal government sued UnitedHealth Group on Tuesday alleging the Minnetonka-based health care company wrongly received from Medicare at least $1 billion in “risk adjustment” payments based on inaccurate data submissions.

The government took issue with what it called “one-sided” chart reviews that focused on maximizing taxpayer dollars to the nation’s largest health insurer, but didn’t correct errors that allegedly inflated the company’s revenue, according to the lawsuit filed in the U.S. District Court for the Central District of California.

Risk adjustment payments are made to private insurers that operate “Medicare Advantage” plans, which are an increasingly popular way for beneficiaries to obtain their government health insurance benefits. Tuesday marked the second time in a few weeks that the Justice Department filed a complaint against UnitedHealth over allegations of inflated risk adjustment payments.

After that opening there is more, with the item, as already noted, online here.

The NYT item noted in the headline, carried in a parallel Strib online item, opens by noting a past handoff by our illustrious Congress to hide a funding shortfall without any inclination to raise taxes which at fifteen years ago would have been at the tailend of Clinton-Gingrich days or early Bush II (i.e., substantially equivalent):

When Medicare was facing an impossible $13 trillion funding gap, Congress opted for a bold fix: It handed over part of the program to insurance companies, expecting them to provide better care at a lower cost. The new program was named Medicare Advantage.

Nearly 15 years later, a third of all Americans who receive some form of Medicare have chosen the insurer-provided version, which, by most accounts, has been a success.

But now a whistleblower, a former well-placed official at UnitedHealth Group, asserts that the big insurance companies have been systematically bilking Medicare Advantage for years, reaping billions of taxpayer dollars from the program by gaming the payment system.

The Justice Department takes the whistleblower’s claims so seriously that it has said it intends to sue the whistleblower’s former employer, UnitedHealth Group, even as it investigates other Medicare Advantage participants. The agency has until the end of Tuesday to take action against UnitedHealth.

In the first interview since his allegations were made public, the whistleblower, Benjamin Poehling of Bloomington described in detail how his company and others like it — in his view — gamed the system: Finance directors like him monitored projects that UnitedHealth had designed to make patients look sicker than they were, by scouring patients’ health records electronically and finding ways to goose the diagnosis codes.

The sicker the patient, the more UnitedHealth was paid by Medicare Advantage — and the bigger the bonuses people earned, including Poehling.

The clear drift, not one perp but several acting in concert, calling to mind the Sherman Act phrase for fault of a "contract, combination or conspiracy in restraint of trade." Textbook stuff, but there will be battling testimony and argument, with the adage "documents are fixed in time and cannot misrecollect." Get your popcorn and watch the movie.

After noting the action is against UnitedHealth AND 14 other firms, the NYT-based item continues:

“They’ve set up a perfect scheme here,” Poehling said in an interview. “It was rigged so there was no way they could lose.”

A spokesman for UnitedHealth, Matthew A. Burns, said the company rejected Poehling’s allegations and would contest them vigorously.

“We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with CMS about our approach under its murky policies,” he said, referring to the Centers for Medicare and Medicaid Services, which administers Medicare Advantage.

Burns also said Poehling’s complaints and similar ones held UnitedHealth and other Medicare Advantage participants to different standards than the ones used by the original Medicare program.

Poehling’s suit, filed under the False Claims Act, seeks to recover excess payments, plus big penalties, for the Centers for Medicare and Medicaid Services. (Poehling would earn a percentage of any money recovered.) The amounts in question industrywide are mind-boggling: Some analysts estimate improper Medicare Advantage payments at $10 billion a year or more.

Under sharia hands would be cut off if allegations are found true in court, but expect a settlement for a specified cash amount without any admission of guilt by anyone; nobody going to the slammer. Expect that, unless Sessions proves better than predecessors in extracting vengeance on behalf of a protuberated public. Indeed, UnitedHealthcare operates worldwide, per their lawn art.

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