Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated 117
A Wall Street Journal analysis has revealed that private insurers in the government's Medicare Advantage program, including UnitedHealth Group, have made numerous questionable diagnoses leading to increased taxpayer-funded payments between 2018 and 2021.
The investigation found instances where patients were diagnosed with conditions they did not have, such as diabetic cataracts and HIV, often without their knowledge. These diagnoses resulted in higher payments from Medicare to the insurers. The Centers for Medicare and Medicaid Services said they are implementing changes to ensure "taxpayer dollars are appropriately spent." The story adds: In all, Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021, the Journal's analysis showed.
The investigation found instances where patients were diagnosed with conditions they did not have, such as diabetic cataracts and HIV, often without their knowledge. These diagnoses resulted in higher payments from Medicare to the insurers. The Centers for Medicare and Medicaid Services said they are implementing changes to ensure "taxpayer dollars are appropriately spent." The story adds: In all, Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021, the Journal's analysis showed.
Ah, there's nothing more 'Murican... (Score:5, Insightful)
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I'd rather deal with insurance companies any day of the week.
I've never been fucked over by an insurance company (even as a cancer patient). Govt fucks me over every day.
But aside from that...if an insurance company fucks you over, at least it's for money. When the govt fucks you over, it's just because it can.
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If you didn't notice, you just weren't paying attention. This is what is desired. (Note that many of the "patients" didn't realize that a severe disease had been entered into their medical history. This can have severe consequences at some later time, when they need treatment.)
Also, insurance is a lousy model for health care. Insurance is for handling unusual risks, and health care is something that people can expect to need.
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If you didn't notice, you just weren't paying attention. This is what is desired. (Note that many of the "patients" didn't realize that a severe disease had been entered into their medical history. This can have severe consequences at some later time, when they need treatment.)
If I understand the article correctly, the patients didn't know because the insurance company made it up. They didn't ACTUALLY have the disease that was reported.
Also, insurance is a lousy model for health care. Insurance is for handling unusual risks, and health care is something that people can expect to need.
That's an interesting thought. Made me cogitate a moment (:
I'm inclined to disagree. It's a large cost that few can pay for out of pocket. Generally, that's a good target for insurance. Your argument seems to be that because it is an INEVITABLE cost, rather than a POTENTIAL cost, insurance isn't the right tool for it. OK - that's a fair critici
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People are always charged for roads they'll never drive on. There are lots of different roads. OTOH, trucks pay a heavier bill than ordinary vehicles, and can't drive on all roads.
If you want to have insurance needed to cover extraordinary use, that would be arguably a reasonable choice. Additionally some medical care should be available to everyone as a public health measure.
Yes, someone's always going to have to pay, but paying an extra set of middlemen grossly adds to the cost.
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Also, insurance is a lousy model for health care. Insurance is for handling unusual risks, and health care is something that people can expect to need.
Two counterpoints:
1) It works alright as a model for the Dutch (and probably others I'm not familiar with). If you want to solve America's cost of healthcare crisis you have to consider other structural factors.
2) As a young(ish) healthy(ish) person I expect to need the occasional check-up and preventative care. I do not expect to need extended hospitalization that could cost tens of thousands, but if I (knock on wood) develop some severe illness it could well happen. Seems like a great case for insu
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I cant get a colonoscopy. Because it is covered one way but if they find something it isnt covered and i am out of pocket $10,000
So where do you like to gamble? Checking one box on a form while asleep changes who has to provide your payments.
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Given your data, I understand you should gamble as often as possible. As long as you are healthy (possibly several decades), the yearly colonoscopy if for free. If one day they find cancer, you pay 10 k$ for the colonoscopy, but you have opportunity to get a treatment, or at least to consider the additional costs and suffering, and decide whether you want it. What did I miss that makes you take the opposite decision?
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As someone who finally got around to getting one, only to be diagnosis with stage 4 colon cancer, i recommend getting one as early as you can.
It's worth the $10K to find out if you have cancer as soon as you can, rather than when it has already spread to the liver like I did.
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Govt fucks me over every day.
Well move to fucking Haiti then if government keeps impeding whatever it is you're doing.
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It doesn't matter who is in office. It is the nature of govt to fuck people over.
Expecting govt to not fuck people over is like expecting a cheetah to not chase down a gazelle.
Re: Ah, there's nothing more 'Murican... (Score:2)
A direct path to chapter 9 for those insurers and their owners. It's time for the government to take control over the healthcare situation in the US.
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And people should thank Richard Nixon for allowing health care to become a for-profit industry.
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Not so much.
https://www.snopes.com/fact-ch... [snopes.com]
We have a US Senator from Florida (Score:5, Insightful)
The problem is a lack of law enforcement. The people in charge of catching these guys get called "bureaucrat" instead of "cop" and get underfunded as a result. The actual cops don't get called in until there's billions and billions in damages. When it's just so over the top nobody can ignore it anymore.
Re: We have a US Senator from Florida (Score:1)
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In a pickle? Take the nickle.
Re:We have a US Senator from Florida (Score:5, Insightful)
Rick Scott was never charged with any crime and wasn't convicted of anything.
True!
His former company Columbia / HCA settled eventually settled with the Federal government for fraud, but that was more than five years after Scott was long gone.
True, and totally weasel-wording. What does it matter when the case was settled, if the fraud itself occurred under his watch?
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Check yourself, cutie. Who are you replying to?
Lying? (Score:5, Informative)
Just because we don't spill the blood of Kings doesn't mean he isn't a Criminal. Then again you guys just made Trump an *actual* King. Guess you'll have to retire your "We're a constitutional republic" Dog Whistle.
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Don't feed the trolls.
What a nightmare! (Score:5, Insightful)
Are there any sane Americans left who still believe the United States has "the best health care system in the world"?
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No, this is Medicare Advantage. The pseudo-privatized version of Medicare created because people like you thought it would be more efficient than the horrible government-run version.
From the article:
Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically [...] Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said.
Shockingly the private for-profit insurance companies have started gaming the system the best they can and aren't more efficient at all. Who could have predicted it.
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Maximizing their shareholder value from all of their revenue sources.
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Are there any sane Americans left who still believe the United States has "the best health care system in the world"?
Depends on your definition of "sane", I suppose. But yeah. Pretty much 100% or close enough of the people who vote Republican think so. Sure they complain about the costs of insurance and actual health care. But they also believe the old lie that regulation is to blame and if only - if only - insurance companies were allowed to market in all states and we'd get rid of the useless insurance commissioners, why prices would drop and only good would come of that.
Re: What a nightmare! (Score:1)
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Are there any sane Americans left who still believe the United States has "the best health care system in the world"?
Some may argue that capitalist greed worshipping shit-heels that benefit from it see it as the best, but I would argue there's a mental disconnect active in a brain that sees profit on human misery as a positive thing.
I will say, this story is refreshing in one way. Usually insurers make money by denying coverage. It's kinda neat to see that they're forcing payment for services not needed for a change, even if extremely aggravating.
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As a cancer patient who has been dealing with medical providers every month for the last two plus years, i don't have many complaints. The ones I do have are very minor.
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For some definitions of "best", sure. Stick with me.
If we're talking about individuals with infinite dollars to throw at their health problem, then yes, evidence backs up the notion that the US has the "best" health care in the world. There are specific areas where other countries may come out ahead, of course, but on the whole it's the US.
If we're talking about population-level health outcomes for all citizens, however, then no, evidence indicates that the US has a fairly okay-to-middling health care syste
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If we're talking about individuals with infinite dollars to throw at their health problem, then yes...
What makes this so tricky (politically) to solve is that you don't actually need infinity dollars. You need one of:
And probably some other avenues that I'm not thinking of. The reality is that a huge number of people, and critically a huge proportion of voters, fall into one of t
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I'd actually argue that at a population level, health insurance—whether from your employer, Medicare, or Medicaid—is not sufficient to move the needle. Outcomes even among those cohorts are below their Western peers, and then it gets worse from there if you're not in one of those cohorts.
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Outcomes even among those cohorts are below their Western peers...
Which outcomes? Patient-reported outcomes following a hip replacement? Rates of hospital-acquired infection? "Door to needle" times for patients who present with symptoms of a stroke? I'm not aware of any research indicating that an insured American patient would receive worse healthcare by such measures at your average American hospital compared to, for example, your average NHS trust.
From your wording I assume you're referring to something more general like life expectancy which will take us into asema
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Quick aside before anything else: the US Census Bureau says that 92.1% of Americans have health insurance [forbes.com]. Read a bit further down and they break it out, but it sounds like ~80% of the US population falls directly into one of your four cohorts, and then the majority of the remainder falls into a fifth cohort you didn't list that is still insured (direct-purchase insurance). So, for all intents and purposes, when we're talking about the US population, we're talking about insured people.
Which outcomes? ... From your wording I assume you're referring to something more general like life expectancy...
That's a fair question
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yeah, everyone over 40 or thereabouts seems to think it's the best. Wait till they get to Germany....
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That's a problem all-around.
At least when it's state run, you avoid fighting the insurancy lobby to impose rules upon them so that they can no longer make you wait until you have permanent fibrosis in your liver before treating your hepatitis.
You're fighting someone either way. Seems to me it's better to fight people who aren't monetarily invested in fucking you over.
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You're a liar. And probably a paid troll.
Insurers couldn't do it without doctors (Score:5, Insightful)
and a government system that's easy to fraud, hard to audit and little consequences if caught..
Re:Insurers couldn't do it without doctors (Score:5, Informative)
In fact, the article specifically says they did it without doctors. They used an obscure Medicare tweak that allowed them to add diagnoses to the Medicare claims that no doctor had actually made. So not only was "diseases no doctor treated," it was also "diseases no doctor diagnosed."
get rid of most of the middle men in health care (Score:5, Insightful)
get rid of most of the middle men in health care and take out a lot of the profit in the system.
Vendors get an lot of profit out of the system as well.
Re: get rid of most of the middle men in health ca (Score:2)
That is what single payer would have done.
Instead we got the ACA writing the insurance companies into the law. Thanks Obama! For implementing Romneycare instead of something good.
There are dozens of Medicaid aid codes (most people aren't eligible for Medicare) which it takes an interview and possibly hours of processing to match up to patients. The aid codes have different eligibility requirements but the whole goal of assigning one is to determine where the money for a person's health care should come from
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That is what single payer would have done.
Not without a whole lot of other reform, it wouldn't have. If the solution to the fact that patients can't afford a $1,000 bag of IV saline that costs $10 in the rest of the world is to have the government step in and pay for the $1,000 bag of saline, you haven't really solved anything. You've just shifted onerous healthcare costs from the uninsured onto the taxpayer (which is maybe a little bit fairer? But it's still not really ideal). The fact that the cost of Medicare (single-payer healthcare for the
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Not without a whole lot of other reform, it wouldn't have. If the solution to the fact that patients can't afford a $1,000 bag of IV saline that costs $10 in the rest of the world is to have the government step in and pay for the $1,000 bag of saline, you haven't really solved anything.
Yes, the other part of the solution is to allow the government to negotiate prices. But doing the one thing AND THEN the other would still have been progress, let alone doing both at once, which WAS the ORIGINAL PLAN for Obamacare before they watered it down to please Rethuglicans.
don't be too quick to knock insurance. It works well enough as a mechanism for healthcare funding in countries like the Netherlands.
Thanks for proving you understand none of the discussion. I am not knocking insurance. I am knocking private insurance. Medicare is, fundamentally, just insurance. All it does is pay for health care.
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Thanks for proving you understand none of the discussion. I am not knocking insurance. I am knocking private insurance.
Private insurance covers the plurality of healthcare costs in the Netherlands. Likely a higher share than in the US where a giant chunk of money comes directly from patients' pockets.
Insurance, private or not, isn't the problem.
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Insurance, private or not, isn't the problem.
The profit is the problem. The private insurance has profit. If you nationalized the private insurance and eliminated the profit you could spend the same money providing more care, or providing care at a lower cost. Therefore private insurance is always a problem, even when the outcomes are better than they are in the US. They could still be better.
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Hate to tell you, but something centrally managed is harder to defraud and easier to audit. The exact opposite of what you believe.
If tech companies like Google and Meta have taught us anything, it's that amassing all your data in one lump makes sifting through it easier than ever.
THE CONSEQUENCES, on the other hand... you're right, those need to be better enforced.
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Yeah, we need medicine ran like the pentagon.
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This particular branch of Medicare is not centrally managed. It is run by private insurers who get reimbursement from Medicare funds.
Re:Insurers couldn't do it without doctors (Score:5, Informative)
Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically [...] Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said.
Re:Insurers couldn't do it without doctors (Score:5, Insightful)
I'm shocked - SHOCKED - that adding profit incentives to charge as much as possible while providing as little as possible has resulted in increased costs.
Well, not that shocked...
=Smidge=
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And there's a reason for no national healthcare (Score:2, Troll)
Like ever other industrialized nation in the world (plus some non, like Cuba)?
Re:And there's a reason for no national healthcare (Score:5, Insightful)
We're talking about Medicare, the closest equivalent the US has.
"National healthcare" would mean doing the same thing to everyone instead of just the elderly.
No, we're talking about Medicare Advantage where private insurers oversee some Medicare benefits, in the promised belief that letting them do so would bring better efficiency and thus cost savings to the taxpayer. The reality is that it brought better revenue-generating efficiency to the insurers and higher costs to the taxpayer. Why does anyone ever believe that it's a good idea to let foxes watch the hen house?
The fact is that this is fraud, plain and simple. Only doctors should ever make diagnoses. Allowing insurers to add their own post-treatment diagnoses is unconscionable, and asking to be ripped off. If you took your car for a brake job and two weeks later the dealership's finance department sent you a bill for suspension work that had never happened you wouldn't pay it. Why is this different?
This is like... (Score:2)
This is like abstinence therapy without handing out the pornography magazines...just saying not to have sex, then billing the government.
JoshK.
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Unless you fuck up your bank or auto manufacturing business. Then the government will send you blank checks.
Fraud (Score:3, Insightful)
All private insurance is a fraud. Private insurance doesn't even make sense. You'd have to be unbelievably stupid to ever think private insurance (of any type) was a good idea.
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Medical insurance against rare and catastrophic medical problems is also a pretty legitimate thing. A big portion of medical "insurance" is more like a pre-payment plane than proper insurance.
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Ah, but you missed the keyword: private. I have nothing against insurance as a concept. It just needs to be centralized, public, and all-encompassing for each insurance type. And there should only be one type of health insurance, one type of auto insurance, etc... all in one easy to setup place.
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Geico is a for-profit company. Meaning they'll do anything they can to NOT pay out. Plus, you have no idea how much of your premiums are actually "going into the pool" versus going into their pockets. There is zero transparency. Rates are determined by a bunch of invisible, and sometimes prejudiced, statistics that they won't share with you.
All private insurance is a fraud because they aren't interested in actually helping people or paying out. None of this would be an issue if there was only one non-profit
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You're describing an opposition to the concept of a for-profit company - not to the concept of private insurance.
When I buy a Geico policy I know what my premiums are. I know the terms of my policy. I can compare them to other insurers to determine if their rates are competitive, and choose another insurer if not. It's much the same as when I buy a $2 can of beans I don't know how much of what I pay is going to the minimum manufacturing and shipping costs vs. what goes to marketing and profit for shareho
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But there shouldn't be competition in insurance. Competition ultimately hurts the amount of money in the pool as does the for-profit nature of their business. Greedy executives who don't do any real work getting paid tons of money that should be in that pool. CEO of Geico, for example, makes multiple millions of dollars per year? Why? What work does he actually do on a day-to-day basis to earn that much? NOTHING. Who cares that you know what the premium is when you don't know if 90% of the money you're fork
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You've disregarded my question of what makes insurance a special snowflake in this regard. Your arguments apply just as well to insurance as they do to manufacturers of canned beans. If you're opposed to for-profit enterprise in general that's fine, but it definitely frames this conversation differently.
If you are trying to insinuate that the garbage way the VA has operated in the past is how this new fictional govt insurance would work, you'd be wrong because you'd still be looking at and comparing the wrong things.
It's wrong to look at the decisions made by a centralized, government run healthcare system the (the VA) on what sort of healthcare to provide and extrapolate to what sort of decisions might be made by a c
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You've disregarded my question of what makes insurance a special snowflake in this regard. Your arguments apply just as well to insurance as they do to manufacturers of canned beans.
No, they don't. Cans of beans are physical products. As they trade hands, money is also exchanged. Insurance is an intangible product. You can't touch or hold the insurance. You can't resell the insurance. You can't consume the insurance. I ignored the question and metaphor because it's a fucking stupid metaphor that doesn't work.
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Stupid god damn quote tags got fucked up.
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It feels arbitrary to draw this distinction between tangible and intangible products, but I suppose I can go with it.
What about my Netflix subscription, or subscription to a cloud backup provider? I can neither touch or hold the agreement I have with those service providers nor can I resell it to another person. I certainly can't eat it. I also have no idea what portion of my fee goes to creating interesting content or to paying for reliable storage infrastructure vs. lining the pockets of shareholders a
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Still doesn't work. Netflix is a service you pay for that delivers a product that does physical exist.
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You'd have to be unbelievably stupid to ever think private insurance (of any type) was a good idea.
That's why the private insurers are written into the ACA. Wouldn't want it to be all good, would we? Got to balance out the pre-existing condition and MEC stuff with private profits.
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You literally just described INSURANCE too. So everyone pays out of pocket and negotiates their own bills?
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Right to health is recognized by the United Nations and implemented in several treaties that UN member states have signed.
States are still required, with immediate effect, to ensure the enjoyment of minimum essential levels of the right to health. They are called minimum core obligations, and the obligation that attaches to them is non-derogable, even in adverse circumstances. Budgets should be ring-fenced to ensure that essential goods and services are universally accessible.
-- https://www.ohchr.org/en/healt... [ohchr.org]
Universal health coverage (UHC) grounded in primary health care helps countries realize the right to health by ensuring all people have affordable, equitable access to health services.
-- https://www.who.int/news-room/... [who.int]
Do something about it! (Score:3)
Yes, be more diligent and try to prevent further fraud. But they need to go after those responsible and hold them accountable - that will deter others from engaging in fraud in the first place, because.... if there's no consequences, why not?! Claw back whatever amount they were fraudulently sent, and then double it as a penalty to the company. Then you need to go to those offices and put on a big show of perp walking anyone responsible out of there and into the back of a police car.
You can't just say "oh, that's haaarrrdddd," and let them get away with $50B in fraud. Or maybe you can, and they'll get elected to the Senate to join the other convicted Medicare fraudster that's sitting there. Maybe that's the retirement plan for Medicare fraudsters is to join the Senate. Hell, we're a coin toss away from putting a convicted felon in the White House, so what's another criminal joining government?
A whole other proxy war! (Score:2)
Gotta love it (Score:5, Interesting)
When you have an actual illness, insurers don't wanna pay for it. When you don't have a disease, the insurers want to mark you with one so they can get paid.
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This has not been my experience.
In April 2022, I had a routine colonoscopy. They could barely start the procedure (and couldn't complete it) because of a mass in my ass.
I was scheduled for a CT Scan 3 days later. A few days after that, I was in front of a colorectal surgeon. A few days after that I was in front of a medical oncologist. Within a month of the colonoscopy, I started chemotherapy. By the end of the year, I had liver surgery (with hospitalization) and a total of 24 chemotherapy sessions and mul
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The math on this doesn't math.
You're old enough for a routine colonoscopy, yet pay $200/month for a platinum plan?
I'm not old enough for a routine colonoscopy and pay more than $200/month for a bronze.
The only way that happens is if you're getting a significant subsidy. Which, based on your later statement about your income taxes, doesn't add up. You can't simultaneously be in a high enough bracket to pay that much in income tax and a low enough one to get health insurance subsidies.
Moving on from that, you
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The flaw in your reasoning is that thinking is not realizing that describing a Healthplan as "platinum" isn't exclusive to the Obamacare exchanges (or whatever they're called). Plans available through one's employer may also be branded as "platinum". My employer also has "gold" and "silver" plans.
Our income is about $300K/year. We're not getting govt subsidies.
As for "the lists", your comments do not aligned with experiences I've read about here, on other forums, the press, or anywhere else one might looks
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Also, I fact checked myself. I logged in to get the exact info. For 2024:
Advantage Platinum Medical Employee Only
Annual Amount 2,808.00
Also, FWIW, I'm currently 53. But hey, I expect to die in the next 12 months, based on the survival rates for a stage 4 colon cancer diagnosis. If I beat the odds, I might make it a year after that. Dying will save me a TON on healthcare costs.
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That's on top of the annual rate increases (Score:2)
Why should I get a colonoscopy when I get an annual 15-30% buttf*cking in the form of a rate increase?
I'm sorry, but the ACA was a monumentally stupid idea and drove all of the small insurers out of business thus limiting your "choice" to one or two companies who can and will raise rates far higher than inflation (or perhaps that's the real rate of inflation...hmmm) because they have no competition anymore.
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I'm sorry, but the ACA was a monumentally stupid idea and drove all of the small insurers out of business thus limiting your "choice"
It's interesting that you put choice in quotes because choice was what you didn't have before the ACA, and still don't have — the ACA made little to no difference in the amount of choice available.
There was nothing preventing "small insurers" from providing MEC. They chose to go out of business rather than provide adequate insurance because there was less profit in it and they would rather invest someplace else.
There is also STILL non-MEC insurance for sale. It's called supplemental insurance. Nothing
Welcome to capitalism (Score:2)
Companies exist to make one thing: money; all else is a side-effect. If making dodgy diagnoses leads to more money being made, that is a good thing in such a company's eyes. Anything that makes more than it loses is good, and if breaking a few rules, doing a few dodgy practices, and paying a few fines, leads to profit on the balance sheet, then that is a good thing. If punished, spending a few million on hotshot lawyers to reduce fines is, again, a good thing. Paying politicians to bend the laws in their fa
They make it cost too much too much to stop (Score:4, Insightful)
The companies do it to a point that it'll cost more to stop them than the government would recuperate, so they mostly get away from it because the cost of enforcement is not paid for.
Patient needs a life saving treatment (Score:2, Funny)
UK - That will be a two year wait
Canada - Have you tried Medically Assisted Dying
As a Canadian you would be lucky to get even this much. For most of us is we would be dead before we got an appointment to see the doctor to find out we were dying. Say what you will about the American system but it at least works most of the time and it pays for the productization of treatments and drugs for the entire world.
C is for Crap (Score:4, Informative)
Part A: inpatient
Part B: outpatient
Part D: prescriptions
Part C: private industry pretending to provide parts A, B and D equivalents, but sacrificing quality of care to make a profit doing it.
All Medicare does is billing. They just pay for stuff. So the idea that there is some lack of efficiency there that the private sector can collect profit from while still somehow making your health care cheaper is not just stupid - it's predatory. The people who have Medicare are mostly older, and therefore easier to take ADVANTAGE of, which is what Part C is really about.
Most people with low incomes have part A paid for by the feds, and in states that GAF about humans, part B is paid by the state. That leaves part D - plans range from free up to hundreds per month depending on what you need covered. There is no need for or benefit from a part C plan. They are all just scams to take advantage of old people confused by insurance. They shouldn't even exist at all.
This has been going on for years (Score:5, Informative)
Fuck all insurance companies (Score:2)
Fuck all insurance companies!
"I saw my opportunities and I took them." (Score:2)
Bane of my existence (Score:2)
Easy Fix: Single Payer (Score:2)
There will still be fraud, but when you remove the layers and costs private insurance add on, it is much easier to disincentivize and detect fraud, especially cases were people up code or change codes to get paid more.
Because you just have one source of data coming in and out.
By the way, actual doctors also play fast and loose with coding, but that's to get paid for actual care.