In what is believed to be the biggest dollar amount scheme committed by a single doctor, Jacques Roy, who owned Medistat Group Associates in DeSoto, Texas, and six others have been indicted on charges of bilking Medicare and Medicaid out of $375 million in phony or unnecessary home visits between January 2006 and November 2011.

According to the indictment, Medistat certified more patients than any other medical practice in the United States during the five-year period the alleged fraud occurred. The 11,000 approvals amount to a whopping 500 times the number of home-health certifications than the average doctor.

The small, four-doctor practice allegedly found its patients by paying home health agency recruiters $50 per beneficiary they found by canvassing a Dallas homeless shelter and by offering free healthcare or food stamps to anyone who signed up and offered their Medicare number. Roy would then “make home visits to that beneficiary, provide unnecessary medical services and order unnecessary durable medical equipment for that beneficiary,” the indictment alleged. “Medistat would then bill Medicare for those visits and services.”

According to HHS, the department did not have the tools to detect the type of anomaly that spurred investigation until recently. “We’re now able to use those data analytic tools in ways–in 2012 and 2011–that no, we really could not have done in years past,” the department’s Inspector General, Dan Levinson, told The Washington Post.

Following the Roy investigation, HHS suspended payments totaling $2.3 million per month to 78 home healthcare agencies in Texas that are suspected of billing irregularities, The Wall Street Journal reported.

Roy has been charged with nine counts of healthcare fraud and one count of conspiracy to commit healthcare fraud. He could face 100 years in prison and a fine of at least $18.5 million, if convicted.

Soon millions of people will shop for health insurance on their own.

The health care overhaul requires nearly everyone to have health insurance, after all, and employer coverage has been slowly, steadily declining.

One way that some health insurers are angling to appeal to millions of new insurance shoppers by opening retail stores where people can buy a policy, check on an existing claim, maybe even take a class in healthy cooking or yoga. Highmark in Pennsylvania and Blue Cross and Blue Shield of Florida are the two insurers that have made the biggest commitment to retail, each with several stores statewide.

Does this make online insurance sellers anxious that insurers may bigfoot their customers and cut into their bottom line? Not at all.

“The better the experience that people have shopping for health insurance, that’s good,” says Sam Gibbs, president of the government systems business for ehealthinsurance.com. “These retail outlets could potentially help all these people to learn about buying insurance.”

The way Gibbs sees it, people just aren’t yet comfortable buying a health plan the way they buy other consumer products, and retail stores might help move the needle and make it seem more routine.

Back in 2005, Costco, for instance, tested health insurance sales with individual policies in Southern California. Now the members-only retailer offers high-deductible plans from Aetna in eight states.

Besides, people are often looking for different experiences when they shop online versus at a store. At retail stores they can ask questions and get lots of one-on-one attention. But when they’re ready to buy, they may go online where prices may be slightly cheaper, he says.

In any case, there’s going to be plenty of business to go around. “They’ll be able to enroll a certain number of people [in retail stores], but they’re not going to be able to handle the mass volume [of insurance shoppers],” says Gibbs.

Avid readers of this blog know the real answer to the anguished question CFO’s often ask when their insurance broker brings in the bad news, i.e, renewal , “Why are my costs going up again!”

It is not an aging population, new and expensive technological advances, cost shifting from government plans that drive medical trend – that is the agreed explanation that brokers, insurance companies and medical providers conspire to convey to ignorant consumers. 

Medical costs are going up because consumers let them and insurance companies and third party administrators are more than happy to assist. Insurance companies dont care what medical costs are – they simply pass 100% of the cost to the consumer, taking a cut as premium dollars are funneled through the system.  The higher the costs, the more third party intermediaries make in lucrative fees.

Since we have studied health care costs for the past four years, learning as much as we can and talking to as many people as we can, we have learned the truth about what drives health care costs. No doubt about our findings – volumes of documents back up the research. Insider information gleaned from talkative industry representatives including retired hospital administrators, industry lawyers and former managed care executives have laid bare a vast conspiracy.

Attempts by this writer, and two others of like mind, to publish articles exposing this vast and pervasive conspiracy in national publications have failed. Advertisers hold sway over editorial decisions it seems.

How to control group health insurance costs?   

If you want to know the truth about health care costs and how several San Antonio employers have cut their medical costs by 40% and more without reducing benefits (Bill Miller Forbes), you may consider attending our upcoming seminar in San Antonio, Texas in April. No tuition fee will be charged, admission is free. You will learn secrets insiders dont want you to know.  You will become armed with information and strategies that will change forever your perception of our current health care system.

Contact Riskmanager@sbcglobal.net  or visit www.costplusinsurance.com

“Once we rid ourselves of traditional thinking we can get on with creating the future” – James Bertrand

Imagine a health plan that requires you to pre-authorize non-emergency claims such as a colonoscopy. Imagine area providers bidding on your medical care. If you can get the colonoscopy for $1,000 instead of $3,000, which one would you choose?

We have found several companies that will negotiate claims for self funded health plans on this basis. This is information on one of those companies – www.primarypc.com

(more…)

The Obama administration’s proposed defense budget calls for military families and retirees to pay sharply more for their healthcare, while leaving unionized civilian defense workers’ benefits untouched.

(more…)

http://www.usccb.org/issues-and-action/religious-liberty/conscience-protection/

http://www.youtube.com/watch_popup?v=G44NCvNDLfc

Do all PPO contracted providers have the same contract? The answer is “NO”.

Molly Mulebriar reports that her cousin, insured by one of the largest health insurance companies in Texas has first hand proof. Mulebriar has an EOB for a specific outpatient CAT Scan for services provided at two different outpatient clinics. Both facilities are within five miles of each other. For the same exact procedure, the PPO contracted price variers by over $1,500.

When asked, a local sales representative for this carrier owned PPO network stated “Bill, all our network providers have agreed to the same pricing. We dont pay one provider more than another provider. We use standard contracts.”

Mulebriar disagrees. “Bill, I have copies of EOB’s that show otherwise. “   (This blog will publish those EOB’s soon).

Same procedure, same exact billing coding, same PPO network, vastly different pricing.

We are now seeing carriers and PPO networks touting new “mini-PPO networks. They are simply carving out those providers who have agreed to lower pricing and calling the network any number of names, such as Platinum Network, etc. We call it the SBPPO Networks (http://blog.riskmanagers.us/?p=7261) – (http://blog.riskmanagers.us/?p=7246)

(more…)

Read the section Costs Compared to Medicare Prices – http://www.nihcr.org/Spending_Variation.html#section4

“How Serigraph dramatically reduced skyrocketing costs while providing better care, and how every company can do the same” , by John Tornius Jr.

Great book on how one company solved ever increasing health care costs.