"The CMS has revealed that it underpays health plans that enroll large numbers of people who are dually eligible for Medicare and Medicaid, and the agency plans to modify its risk-adjustment model to make up for the underpayment.

In response to persistent and vocal complaints from health plans questioning the accuracy of the CMS' model for predicting costs of dual-eligible beneficiaries, the agency conducted a retrospective analysis of its 2014 plan data.

The CMS uses a prospective model (called the CMS-HCC) to calculate risk scores, using health status in a base year to predict costs in the following year. Those scores drive adjustments to capitated payments made for elderly and disabled beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration programs.

“Our findings show that the community segment of the 2014 model … somewhat underpredicts for full-benefit, dual-eligible beneficiaries,” the CMS said in an under-the-radar notice sent to plans on Oct. 28. The agency did not reveal a dollar amount for the underpayment.

In the highly technical document, the agency outlined some tweaks to its risk model that officials believe will lead to more accurate payments to plans. The CMS is seeking comments on the proposed alterations by Nov. 25, and will publish final changes in a notice for the following payment year in February 2016."

Read more at Modern Healthcare

Too many to post individually over the last few days:

Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery
California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme
Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims
Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case
Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid



Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery.

"WASHINGTON (AP) -- Bristol-Myers Squibb will pay $14.6 million to settle charges from U.S. regulators that its joint venture in China gave cash and other benefits to government health care providers to boost drug sales.

The Securities and Exchange Commission announced the settlement of civil charges Monday with the company, one of the largest drugmakers in the world. Bristol-Myers Squibb, based in New York, makes and sells prescription and over-the-counter medicines worldwide."

Read more at AP



California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme

"LOS ANGELES – A Placentia woman pleaded guilty Monday to a federal charge stemming from the operation of a hospice that submitted millions of dollars in fraudulent bills to Medicare and Medi-Cal.

Sharon Patrow, 44, entered her plea to a health care fraud count before U.S. District Judge S. James Otero, who set a May sentencing date. Patrow's mother, Priscilla Villabroza -- who is serving a 4 1/2-year term at a federal prison in Victorville for running a separate health care fraud scheme -- is also charged in the case.

The mother and daughter, along with four others, were charged in December with 25 health care fraud and money laundering counts, each of which carries a potential multiple-year prison sentence, according to the U.S. Attorney's Office.

The case involves the formerly Covina-based California Hospice Care, which Villabroza purchased in late 2007 while under investigation in the earlier case, prosecutors said.

Officials allege that between March 2009 and June 2013, California Hospice submitted nearly $9 million in fraudulent bills to Medicare and Medi- Cal for purportedly providing end-of-life care to patients who were, in fact, not dying. The public health programs paid nearly $7.5 million on those allegedly bogus bills."

Read more at OC Register



Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims

"COLUMBUS — Last week, the hospital business in Georgia’s second-largest city received a double dose of financial misery. The first round of bad news centered on Columbus Regional Health. State Attorney General Sam Olens announced Friday that Columbus Regional and other related entities had agreed to pay Georgia and the United States up to $35 million to resolve allegations of false Medicaid claims.

Then the Columbus Ledger-Enquirer reported Saturday that the other hospital organization in town, St. Francis, has been told by the feds that it must repay $21.4 million and make major changes in the way it does business. The federal audit report came 10 months after St. Francis said it could not account for about $30 million on its financial books."

Read more at Albany Herald



Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case

"A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes.


Guardian Hospice set aggressive targets to recruit and enroll patients it knew were not in the last months of their lives so it could collect Medicare payments, the federal government alleged. In agreeing to the settlement, the for-profit company, which serves the Atlanta area, did not admit liability."

Read more at AJC




Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid

WASHINGTON: Three health and safety net programs for the poor and elderly accounted for most of the federal government’s $124.7 billion in improper payments in fiscal 2014, the Government Accountability Office reported Thursday.

"The figure, which represents improper payments across 124 federal programs, is up roughly 20 percent from $105.8 billion in fiscal 2013, according to a new GAO report.

Most of the $19 billion increase resulted from erroneous payments under the Medicare, Medicaid and Earned Income Tax Credit programs. They account for more than 75 percent of the GAO’s government-wide improper payment estimate.

Improper payments are those made in error or in an incorrect amount and can include duplicate payments, those made without proper documentation or to ineligible recipients, and payments for ineligible goods and services.

They can result from fraud, unintentional clerical errors or a host of other reasons.

Nearly $1 trillion in improper federal payments have been made since 2003, when a federal law began requiring certain agencies to report the amounts."

Read more at McClacthyDC

"Super-utilizers are the frequent fliers of the health care system, whose serious illnesses send them to the hospital multiple times every year and cost the system hundreds of thousands of dollars annually. Figuring out how best to address these patients’ needs and reduce their financial impact on the health care system is a subject of intense interest among policymakers. Now a new study has found that, in contrast to the notion that “once a super-utilizer, always a super-utilizer,” many patients who use health care services intensely do so for a relatively brief period of time.

Research and news reports often point out that super-utilizers are often uninsured or on Medicare and Medicaid and account for a large percentage of health care spending. Federal officials have suggested that their “large numbers of emergency department [ED] visits and hospital admissions … might have been prevented by relatively inexpensive early interventions and primary care.” Many of the programs that have been developed to reduce super-utilizer health care use have focused on the needs of people with multiple chronic conditions, ensuring they have a medical home through which their care is coordinated, for example, or addressing their social services needs."

Read more on Kaiser Health News

"The CMS lowered its final increase for hospitals rates in 2016 to a scant 0.9%, down from the 1.1% increase it proposed in April. The move will heighten pressure on the nation's 3,400 acute-care hospitals to rein in costs and reduce unnecessary spending.

The 435 long-term care hospitals certified by Medicare will see a 4.5% cut in their payments in fiscal 2016, which begins Oct. 1. The CMS on Friday posted a final rule that said long-term care hospitals can expect to see a decrease in payments by $250 million next year.

The inpatient prospective payment system is meant to create incentives that encourage efficiency and reduce unnecessary costs in U.S. hospitals that offer care to Medicare beneficiaries. The changes outlined will further those goals, the CMS says, while maintaining the financial viability of the hospital industry and ensuring access to high quality healthcare for Medicare beneficiaries."

Read more at Modern Healthcare