Archive for June, 2008
Many states do a poor job of regulating Medicaid fraud because it is a not a simple matter economically. After all, for ever dollar Medicaid brings into a state, there is a federal matching dollar hat the state receives. Some states even overpay Medicaid providers, collect matching federal funds, and collect kickbacks of overpayments, thus becoming part of the fraud problem.
The question then becomes, what is the sense behind turning the oversight of Medicaid over to the same government that is participating in the fraud? Their actions have created long waiting lists, rationing of care and poor delivery of not enough care, again controlled by the government.
There is another side to the issue, however. What happens when you need to make the numbers work? It’s important to look at the major problem. There are many honest and caring physicians who try to help as many individuals on Medicaid as possible. The problem is that even the busiest physicians that take Medicare can’t take more than about 28% of their caseload in Medicaid patients, they can’t afford to stay in business because the amount they are reimbursed is lower than the services provided. Therefore, if there are too many Medicaid patients seeing a particular doctor, he loses money until he can’t afford to stay in business any more.
We haven’t even talked about the number of children covered by Medicaid for various reasons. There are over 25 million kids that have various forms of Medicaid coverage. There are Targeted Case Workers and Case Management through Medicaid Rehabilitative Services who do all they can to deal with children’s’ physical and mental disabilities – getting help and services for them while keeping expenses to Medicaid and to physicians under control. A federal-state partnership that exists now to cover these expenses could be eliminated if some politicians get their way.
Looking at both sides, the hope is that the politicians will be able to work with the expenses while remembering that these issues are not only about finances, but at the heart of the issues are children and adults with vulnerabilities and disabilities that depend on the Medicaid system to help keep them well.
Walgreens Drug Stores agreed today to pay $35 million to the federal government for fraudulent activities regarding three prescription drugs. What was at the heart of the case was that Walgreen was switching out the prescribed drugs for more expensive brands and by switching these, they substantially increased the amount of money that Medicaid reimbursed them, thus substantially increasing their profits.
Medicaid recipients were unaware of this, and there has been no disclosure in the suit that any recipients were harmed, however, switching medication is not harmless. Just because it seems so far that nobody was hurt or killed in this situation, there are severe penalties for these practices because serious risks do exists. Plus, switching medications for profit is simply put, illegal.
Switching medications in this way is a violation of state and federal regulations that are designed to protect patients. In addition, pharmacies subject themselves to triple damages, civil penalties and attorneys’ fees. Usually, this, plus the willingness of insiders to report such fraudulent activities helps keep pharmacies in line with regulations, however, this case against Walgreens should be a warning that the government will pursue fraud aggressively.
For Medicaid recipients, it is important that you know that this what Walgreens did in this case is not the same as the pharmacy calling your doctor and asking if the medications could be switched. That is a practice that pharmacies use if they are trying to correctly fill a prescription with a substitute generic medication. In the Walgreens case, thousands of prescriptions were replaced without notifying anyone, and that is totally against regulations.
This case should let you know that if you receive Medicaid benefits, there are agencies looking out for your welfare and trying to protect you, and reassure you that most pharmacies try to help their clients by filling the right prescriptions and doing the right thing.
The Senate and House have been grappling with the budget for months now. There have been many different viewpoints included some pointed and heated debates with the President, with promises of vetoes.
Yesterday, the Senate passed a $3.1 Trillion budget which will pass the burden of balancing the budget and dealing with tax issues that will likely affect Medicare and other important benefits. As the candidates for President assess their plans and responsibilities, as well as their priorities, they will need to be thinking about how to balance the budget while saving essential programs and services such as Medicare.
The annual budget debate in Congress provides for a non-binding resolution that opens the way for later bills that will affect taxes and, of course, Medicare and other programs. For now, though, the budget offered by Congress will extend some tax breaks for businesses, and will prevent doctors from having to absorb the proposed cuts in their Medicare payments.
Though this is a band aid for now, it is not a way to solve the issues in the long term. Medicare recipients could be hit with less reimbursement to doctors, less procedures that are covered and stricter guidelines and oversight as to what is actually “medically necessary.” Of course, services and procedures must be considered “medically necessary” in order to have Medicare pay for them.
The other issue regarding cutting repayment to doctors is also an issue that will need to be addressed when the next President grapples with the budget. Though there is a delay for now, the issue will be right back on the table and needs to be dealt with as efficiently as possible so that the issue is resolved quickly and fairly and everyone involved in the Medicare system – especially patients and doctors – can move forward with more certainty.
It will be important to watch and see what happens during and after the election and see how things pan out. Though the picture does not look rosy, there are a number of ways to help the Medicare system and a number of ideas that are being considered.
For now, at least, benefits are staying as is, and will be dealt with, most likely in 2009, after the political hoopla settles down and Washington get back to the real nuts and bolts business of running the government.
Individuals with terminal illnesses have the right to choose their end-of-life care. That has long been an issue that has received attention from individuals, families, the public, hospitals, insurance companies and more.
The Center for Medicare and Medicaid Services (CMS) has now put this information in writing, including it in the outline of a new regulation regarding this issue. CMS will publish and release the outline later this year.
Previously, there was no specific language regarding individual patient’s rights in regulations. This new regulation is the first update since 1983, when Hospice care and end-of-life rights were not as wide an issue as they have become now.
Many Hospice patients are already very involved in their rights, care and treatment, as well as their wishes as they come to the end of their life, however, now that there is a specific regulation with language in place which details and reinforces those rights, there is stronger protection for those who might want to explain their wishes but need the support to do so.
Some of the rights of individuals involved in Hospice care or palliative care include participation in their treatment plan, the right to effective pain management, the right to refuse treatment and the right to choose their own physician.
Hospice care can be chosen when a patient decides that curative care is no longer an option for them. By choosing Hospice care, they are choosing to receive care that will provide comfort and care to themselves and sometimes to the family members, as well. This type of care can be provided at home as well as in an inpatient setting. Nearly one million Medicare beneficiaries are receiving Hospice care at any given time.
Updating the regulation and reinforcing patients rights – on paper – is an important step in making sure that the individuals who are making decisions about end-of-life issues do not have to struggle with the emotional issues involving deciding on care and receiving support.
After taking a long look at the way payments to Medicare in many Florida counties are paid, there seem to be a number of inequities. Payments in Miami-Dade counties are 38% higher than in a number of counties and 50% higher than in 24 other counties. In addition, the other counties receive fewer benefits than plans in Miami-Dade.
Somehow this has a lot to do with the way that the counties are districted. To help adjust the situation, next year Miami-Dade will receive a 13% payment increase, while other counties only receive 3% to 4% increases. This will be the beginning of trying to make the Medicare situation more equitable throughout the state.
Florida is not the only state that struggles with some of these issues, however, they are, at present, addressing the issues and tackling them to make the financial ramifications of premiums and payments much more fair and equitable.
Representative Robert D. Wexler, a Democrat, is expected to legislation next week that will change the way that Medicare calculates payments to private health plans in various counties. To this point, has mandated that payments are calculated on a county basis. Miami-Dade has been billed more on a per person basis, leading to the difference in the rates for Miami-Dade, vs. the other counties in question.
Wexler’s proposal would require HHS to close the payment gap until Palm Beach County’s rates are within 3% of Miami-Dade’s by 2012. The bill would lower the Miami-Dade payments and use that money to raise payments in Palm Beach County.
Some of this may sound complicated, but the main issue – especially for the people of Florida – is that there will be a fair and equal distribution of benefits for everyone. This is actually important and trendsetting, because Los Angeles may be the next place they look.
When elderly individuals go into along term care facility or a similar facility and self pay, the cost can be astronomical. Making sure that the person is comfortable, well cared for, in a clean environment and positive atmosphere is not a low budget issue. What happens, though, when a private pay individual converts to Medicaid?
Well, one would think that because all of the payments are now guaranteed, albeit possibly lower, that these facilities that have been raking in money from these individuals and their families, that they would leave grandma, grandpa or aunt Minnie in comfort and without worry without changing a thing.
Unfortunately, this doesn’t always happen. In fact, there is an investigation taking place in New Jersey regarding the company Assisted Living Concepts, owner of eight assisted living homes in southern New Jersey. The investigation was started by the Public Advocate for the state, who has filed papers against the company because of their alleged practice of discharging the elderly when they change from self pay to Medicaid.
Public Advocate Ronald K. Chen is asking for the names, admission and discharge summaries, as well as contact information for every resident of the company who is or has been a Medicaid beneficiary.
Chen says that the investigation was sparked because there is an indication that this company “is placing elderly vulnerable residents at risk by displacing them from their homes in violation of ALC’s state license. Our primary concern is to protect the safety well being and peace of mind of these residents.”
The representative of Assisted Living Concepts, Laurie Bebo, who is also the CEO of the company, refuses to cooperate with the subpoena and states that the company does not have any Medicaid conditions in their license; therefore, they do not have to honor Medicaid patients.
Chen says that state licenses for all eight facilities stipulate that at least 30% of the residents of each of the facilities are to be Medicaid eligible and no resident would be discharged because or if they spent all their money.
Assisted Living Concepts operates more than 200 assisted living residences in 17 sates, containing more than 8,000 units, so this is no small issue. New Jersey may just be the tip of the iceberg.
When elderly individuals go into a long term care facility or assisted living facility and self pay, the cost can be astronomical. Making sure that the person is comfortable, well cared for, in a clean environment and positive atmosphere is not a low budget issue. What happens, though, when a private pay individual converts to Medicaid?
Well, one would think that because all of the payments are now guaranteed, albeit possibly lower, that these facilities that have been raking in money from these individuals and their families, that they would leave grandma, grandpa or aunt Minnie in comfort and without worry without changing a thing.
Unfortunately, this doesn’t always happen. In fact, there is an investigation taking place in New Jersey regarding the company Assisted Living Concepts, owner of eight assisted living homes in southern New Jersey. The investigation was started by the Public Advocate for the state, who has filed papers against the company because of their alleged practice of discharging the elderly when they change from self pay to Medicaid.
Public Advocate Ronald K. Chen is asking for the names, admission and discharge summaries, as well as contact information for every resident of the company who is or has been a Medicaid beneficiary.
Chen says that the investigation was sparked because there is an indication that this company “is placing elderly vulnerable residents at risk by displacing them from their homes in violation of ALC’s state license. Our primary concern is to protect the safety well being and peace of mind of these residents.”
The representative of Assisted Living Concepts, Laurie Bebo, who is also the CEO of the company, refuses to cooperate with the subpoena and states that the company does not have any Medicaid conditions in their license; therefore, they do not have to honor Medicaid patients.
Chen says that state licenses for all eight facilities stipulate that at least 30% of the residents of each of the facilities are to be Medicaid eligible and no resident would be discharged because or if they spent all their money.
Assisted Living Concepts operates more than 200 assisted living residences in 17 sates, containing more than 8,000 units, so this is no small issue. New Jersey may just be the tip of the iceberg.
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