A decade in the past, federal officers drafted a plan to discourage Medicare Benefit well being insurers from overcharging the federal government by billions of {dollars} — solely to abruptly again off amid an “uproar” from the business, newly launched court docket filings present.
The Facilities for Medicare & Medicaid Providers printed the draft regulation in January 2014. The rule would have required well being plans, when analyzing affected person’s medical data, to establish overpayments by CMS and refund them to the federal government.
However in Might 2014, CMS dropped the thought with none public clarification. Newly launched court docket depositions present that company officers repeatedly cited concern about strain from the business.
The 2014 determination by CMS, and occasions associated to it, are on the heart of a multibillion-dollar Justice Division civil fraud case in opposition to UnitedHealth Group pending in federal court docket in Los Angeles.
The Justice Division alleges the enormous well being insurer cheated Medicare out of greater than $2 billion by reviewing sufferers’ data to search out extra diagnoses, including income whereas ignoring overcharges which may scale back payments. The corporate “buried its head within the sand and did nothing however maintain the cash,” DOJ stated in a court docket submitting.
Medicare pays well being plans increased charges for sicker sufferers however requires that the plans invoice just for situations which are correctly documented in a affected person’s medical data.
In a court docket submitting, UnitedHealth Group denies wrongdoing and argues it shouldn’t be penalized for “failing to comply with a rule that CMS thought-about a decade in the past however declined to undertake.”
This month, the events within the court docket case made public 1000’s of pages of depositions and different data that supply a uncommon glimpse contained in the Medicare company’s long-running wrestle to maintain the personal well being plans from taking taxpayers for a multibillion-dollar experience.
“It’s simple to dump on Medicare Benefit plans, however CMS made an entire boondoggle out of this,” stated Richard Lieberman, a Colorado well being knowledge analytics knowledgeable.
Spokespeople for the Justice Division and CMS declined to remark for this text. In an e-mail, UnitedHealth Group spokesperson Heather Soule stated the corporate’s “enterprise practices have at all times been clear, lawful and compliant with CMS laws.”
Missed Diagnoses
Medicare Benefit insurance policy have grown explosively in recent times and now enroll about 33 million members, greater than half of individuals eligible for Medicare. Alongside the way in which, the business has been the goal of dozens of whistleblower lawsuits, authorities audits, and different investigations alleging the well being plans usually exaggerate how sick sufferers are to rake in undeserved Medicare funds — together with by doing what are referred to as chart critiques, supposed to search out allegedly missed analysis codes.
By 2013, CMS officers knew some Medicare well being plans had been hiring medical coding and analytics consultants to aggressively mine affected person recordsdata — however they doubted the company’s authority to demand that well being plans additionally search for and delete unsupported diagnoses.
The proposed January 2014 regulation mandated that chart critiques “can’t be designed solely to establish diagnoses that might set off extra funds” to well being plans.
CMS officers backed down in Might 2014 due to “stakeholder concern and pushback,” Cheri Rice, then director of the CMS Medicare plan fee group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the business’s response as an “uproar.”
Precisely who made the decision to withdraw the chart assessment proposal isn’t clear from court docket filings to this point.
“The path that we obtained was that the rule, the ultimate rule, wanted to incorporate solely these provisions that had huge, you realize, widespread stakeholder assist,” Rice testified.
“So we didn’t transfer ahead then,” she stated. “Not as a result of we didn’t suppose it was the precise factor to do or the precise coverage, however as a result of it had combined reactions from stakeholders.”
The CMS press workplace declined to make Rice out there for an interview. Hornsby, who has since left the company, declined to remark.
However Erin Fuse Brown, a professor on the Brown College Faculty of Public Well being, stated the choice displays a sample of timid CMS oversight of the favored well being plans for seniors.
“CMS saving cash for taxpayers isn’t sufficient of a purpose to face the wrath of very highly effective well being plans,” Fuse Brown stated.
“That’s extraordinarily alarming.”
Invalid Codes
The fraud case in opposition to UnitedHealth Group, which runs the nation’s largest Medicare Benefit plan, was filed in 2011 by a former firm worker. The DOJ took over the whistleblower go well with in 2017.
DOJ alleges Medicare paid the insurer greater than $7.2 billion from 2009 via 2016 solely based mostly on chart critiques; the corporate would have obtained $2.1 billion much less if it had deleted unsupported billing codes, the federal government says.
The federal government argues that UnitedHealth Group knew that many situations it had billed for weren’t supported by medical data however selected to pocket the overpayments. As an illustration, the insurer billed Medicare almost $28,000 in 2011 to deal with a affected person for most cancers, congestive coronary heart failure, and different severe well being issues that weren’t recorded within the individual’s medical report, DOJ alleged in a 2017 submitting.
In all, DOJ contends that UnitedHealth Group ought to have deleted greater than 2 million invalid codes.
As an alternative, firm executives signed annual statements testifying that the billing knowledge submitted to CMS was “correct, full, and truthful.” These actions violated the False Claims Act, a federal regulation that makes it unlawful to submit bogus payments to the federal government, DOJ alleges.
The complicated case has featured years of authorized jockeying, even pitting the recollections of key CMS workers members — together with a number of who’ve since departed authorities for jobs within the business — in opposition to these of UnitedHealthcare executives.
‘Pink Herring’
Court docket filings describe a 45-minute video convention organized by then-CMS administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she arrange the assembly between UnitedHealth and CMS workers on the request of Larry Renfro, a senior UnitedHealth Group govt, to debate implications of the draft rule. Neither Tavenner nor Renfro attended.
Two UnitedHealth Group executives on the decision stated in depositions that CMS staffers informed them the corporate had no obligation on the time to uncover misguided codes. One of many executives, Steve Nelson, referred to as it a “very clear reply” to the query. Nelson has since left the corporate.
For his or her half, 4 of the 5 CMS staffers on the decision stated in depositions that they didn’t keep in mind what was stated. Not like the corporate’s group, not one of the authorities officers took detailed notes.
“All I can inform you is I keep in mind feeling very uncomfortable within the assembly,” Rice stated in her 2022 deposition.
But Rice and one different CMS staffer stated they did recall reminding the executives that even with out the chart assessment rule, the corporate was obligated to make a good-faith effort to invoice just for verified codes — or face potential penalties below the False Claims Act. And CMS officers strengthened that view in follow-up emails, in keeping with court docket filings.
DOJ referred to as the flap over the ill-fated regulation a “pink herring” in a court docket submitting and alleges that when UnitedHealth requested for the April 2014 assembly, it knew its chart critiques had been below investigation for 2 years. As well as, the corporate was “grappling with a projected $500 million price range deficit,” in keeping with DOJ.
Information Miners
Medicare Benefit plans defend chart critiques in opposition to criticism that they do little however artificially inflate the federal government’s prices.
“Chart critiques are certainly one of many instruments Medicare Benefit plans use to assist sufferers, establish persistent situations, and forestall these situations from changing into extra severe,” stated Chris Bond, a spokesperson for AHIP, a medical health insurance commerce group.
Whistleblowers have argued that the cottage business of analytics corporations and coders that sprang as much as conduct these critiques pitched their companies as an enormous moneymaking train for well being plans — and little else.
“It was by no means reputable,” stated William Hanagami, a California legal professional who represented whistleblower James Swoben in a 2009 case that alleged chart critiques improperly inflated Medicare funds. In a 2016 determination, the ninth Circuit Court docket of Appeals wrote that well being plans should train “due diligence” to make sure they submit correct knowledge.
Since then, different insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart critiques. In July 2023, Martin’s Level Well being Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for situations starting from diabetes with issues to morbid weight problems. The plan denied any legal responsibility.
A December 2019 report by the Well being and Human Providers Inspector Common discovered that 99% of chart critiques added new medical diagnoses at a value to Medicare of an estimated $6.7 billion for 2017 alone.
