Tuesday, October 15, 2013

Aetna Announces Major Expansion Of Medicare Advantage Network

Aetna is expanding its network of doctors to treat Medicare Advantage customers into new territory, growing its geographic reach and physician base in 22 states, including Connecticut.
The expansion applies to more than 450,000 people in the U.S. who have Aetna’s employer-sponsored Medicare Advantage group health plans, which some businesses offer to their retirees. Aetna also has about 480,000 customers in its individually sold Medicare Advantage plans, for which there will be a network change announced in the near future, the company said.
Aetna and other health insurers have made major investments in recent years to bolster their services for Baby Boomers, who are increasingly reaching the Medicare eligibility age of 65.
The announcement Monday comes less than two weeks after one of Aetna’s major competitors, UnitedHealthcare, sent notices to Connecticut doctors saying they have been cut from the company’s Medicare Advantage network for next year. A UnitedHealthcare spokesman on Friday said the network cuts will “ultimately provide better outcomes for people in Connecticut while we and others manage through the severe government funding cuts in Medicare Advantage.”
Aetna said it is growing its network of doctors by 59 percent next year and expanding its territory from 442 counties to 703.
The expanded territory includes 87 additional counties in Texas — about one third of the state’s total. Aetna is broadening its Medicare Advantage reach by 49 counties in Indiana; 43 counties in Georgia; and 22 counties in Illinois.
The Hartford health insurer also is adding doctors to its networks in Arizona, Connecticut, Kentucky, Maine, Maryland, Michigan, Missouri, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Virginia, Washington and Wisconsin.
“We’re very excited about this network expansion, which is one of our biggest ever,” Nancy Cocozza, president of Medicare Business for Aetna, said in a prepared statement. “Strengthening our network in group Medicare is important as it enables nationwide coverage for large, national employers, and it lets retirees continue receiving care from doctors they used and trusted while they were employed.”
The open enrollment period for Medicare plans starts Tuesday and ends Dec. 7. In addition to Medicare Advantage, Aetna has about 341,000 customers of its Medicare Supplement plans. Separately, the insurer also sells stand-alone prescription drug plans to Medicare-aged customers.
Medicare is federal government-funded health insurance primarily for people 65 and older. Medicare Advantage is a version of Medicare Parts A and B, hospital and medical coverage, administered by private insurers. The insurers are paid by the federal government to provide coverage. Often, private insurers compete for market share by offering additional benefits, such as discounts on dental coverage, eyewear or hearing-aid services, in addition to exercise programs or gym memberships.
UnitedHealthcare Cuts Back
Last week, the Fairfield County Medical Association said doctors were calling the organization to say they received letters notifying they had been cut from UnitedHealthcare’s network. The association says UnitedHealthcare is cutting 810 primary care physicians and 1,440 specialists. The insurer declined to say how many doctors have been cut, but UnitedHealthcare has said it will have an adequate network that includes more than 1,500 primary care physicians and more than 4,000 specialists.
UnitedHealthcare’s decision drew criticism from the Connecticut State Medical Society, American Medical Association, U.S. Sen. Richard Blumenthal, D-CT, and U.S. Rep. Joe Courtney, D-2ndDistrict. State Attorney General George Jepsen inquired on Friday about the matter, though Jepsen’s  spokeswoman said Medicare Advantage is a federally regulated matter.
Many of the questions about UnitedHealthcare’s decision to cut its network can only be answered by the federal Centers for Medicare & Medicaid Services, which manages Medicare Advantage. However, a federal government shutdown has left most of the federal Medicare employees furloughed.

Robstown Doctor Accused of Medicare and Medicaid Fraud

Posted: Oct 14, 2013 2:26 PM by Jessica Holley - jholley@kristv.com 
Updated: Oct 14, 2013 7:05 PM
 Robstown Doctor Accused of Medicaid Fraud
  •  Robstown Doctor Accused of Medicaid Fraud
  •  Robstown Doctor Charged with Billing Fraud- KZTV

ROBSTOWN - A Robstown doctor is facing nine decades behind bars after a Grand Jury indicted him on nine counts of Medicare and Medicaid fraud and five counts of mail fraud and identify theft.
Authorities on Friday arrested Dr. Roque Ramirez, owner of Calallen-based Health Resolutions Inc., and charged him with filing 4,970 false claims over a three and a half year period starting in December, 2008.
The Texas Attorney General's Office says the claims were worth more than $1.4 million and that in some instances, the doctor filed claims for dead patients.
Officials say Ramirez was also out of the state and country on the days he wrote on the forms. The indictment says his billing, in some cases, would have required him to work more than a 24 hour day.
Ramirez will be arraigned Wednesday morning at the Federal Courthouse. He asked the court to provide him an attorney.
No one answered the door to his home, listed in Robstown, on Monday and his clinic was vacant.

Pay For Hospital CEOs Linked More To Technology, Patient Satisfaction Than Quality, Study Finds

OCT 14, 2013
What do hospital boards value in a chief executive? A new study of CEO pay at nonprofit hospitals finds that executives at institutions that have a lot of fancy medical technology and high patient satisfaction are paid more than their peers. But running a hospital that scores well on keeping more patients alive or providing extensive charity care does not translate into a compensation bump.
"The finding on quality is disappointing: It says that most boards are more focused on the fanciest technology around," said Dr. Ashish Jha, a professor at the Harvard School of Public Health and one of the study’s authors. "This paper suggests that maybe we need to pay a little more attention to other more important outcomes, such as whether your patients are dying at a high rate or not."
CEOs of technology-laden nonprofit hospitals earned on average $136,000 more than those with little advanced machinery, according to the study published Monday in the journal JAMA Internal Medicine. CEOs at places with high patient satisfaction scores earned on average $52,000 more than those with poor reviews.
The study found no difference in CEO compensation depending on publicly available measures of quality, including mortality rates, readmissions rates and how consistently hospitals followed a number of publicly reported guidelines for recommended care. This results are in line with a report last year that focused on New Hampshire hospitals and also found no relationship between CEO pay and quality of care.
For some time, nonprofit hospitals have been under scrutiny for paying lavish salaries to CEOs while giving little back to their communities. Dr. Karen Joynt, the study's lead author, said that since nonprofit hospitals do not have to pay any property taxes, the researchers wanted to see if there was any evidence hospital boards gave financial rewards to CEOs to provide more charity care, such as treating lots of low-income patients and discounting or waiving bills for those who had trouble paying. "We didn't see a signal at all," she said.
The study is the first to use federal tax returns of hospitals to assess CEO pay and the factors that are associated with it. The researchers examined records for 2,581 hospitals, more than 98 percent of private nonprofit hospitals. For-profit hospitals, which are a minority of America’s acute care hospitals, were not included in the analysis. The analysis identified 1,877 executives, with some running more than one hospital.
The researchers compared the highest performing hospitals with the lowest performing hospitals after adjusting for all other factors, such as the size, whether the hospital was located in an expensive part of the country and whether it was an academic medical center or community hospital. They also adjusted for CEOs who ran more than one hospital.
The average CEO compensation was $595,781 in 2009, the most recent year for which the tax returns were publicly available when the study began. As would be expected, the study found that CEOs who ran bigger hospitals were paid more -- an average of $550 more per bed. CEOs of academic medical centers were paid $425,000 more than CEOs running nonteaching hospitals.
The researchers employed a technology index that assessed the number of advanced machines such as MRIs and positron-emission technology, also called PET scans. The index also factored in whether the hospital performed complex operations such as transplants and open-heart surgery. The researchers divided the hospitals into four groups, based on this index. The average CEO compensation at hospitals in the group with the most technology—after all other factors were taken into account —was $664,000, while the average compensation for CEOs at hospitals in the group with least amount of sophisticated technology was $528,000, 26 percent lower.
Dr. Warren Browner, the CEO of the California Pacific Medical Center in San Francisco, questioned the paper’s conclusions in a commentary that the journal also published. He wrote: "Their conclusion that advanced technology drives CEO pay might be right, but an observational design cannot rule out alternatives, such as CEOs at fancier hospitals earn more because they are worth more, or because the members of the board compensation committees at glitzy hospitals are more accustomed to higher incomes."
Browner disputed the researchers' suggestion that hospital boards need to place more emphasis on quality when setting compensation, saying that already is a widespread practice. He suggested that hospital boards may be judging CEOs using internal metrics that are different than those available to the Harvard researchers.
The researchers acknowledged that possibility, but said that the public measures, such as mortality, should be relevant in assessing any hospital leader. "It's hard to argue that death rates after a heart attack don't matter," Jha said.
They found that on average, the group of hospitals with the highest patient satisfaction scores paid their CEOs nearly $626,000 while CEOs of hospitals in the group with the lowest scores earned $574,000. Patient satisfaction is considered one marker of quality, although there is disagreement about how much it is influenced by extraneous factors such as the lavishness of the hospital facilities.
Browner wrote that it would not be surprising if hospitals used the public patient satisfaction measures as a metric, but wrote that it was “unclear” whether those reflect medical quality. "Indeed, at our hospital, overall patient satisfaction is markedly higher among those who were in private rooms," he wrote. "So, too, is their satisfaction with the physicians, nurses, tests and treatments, and even the food! Talk about a halo effect."

Alabama Pain Center undergoing months-long audit to close Nov. 15 unless Medicare payments resume

Alabama Pain Center
The Alabama Pain Center on 600 Whitesport Drive. S.W. in Huntsville. (Lucy Berry | lberry@al.com)
Lucy Berry | lberry@al.comBy Lucy Berry | lberry@al.com 
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on October 14, 2013 at 6:34 PM, updated October 14, 2013 at 6:51 PM

HUNTSVILLE, Alabama – The suspension of Medicare payments in late August and a dwindling supply of financial reserves will force the Alabama Pain Center to close its doors Nov. 15 unless payments resume, the clinic announced late Monday afternoon.
The Alabama Pain Center, which operates clinics on 600 Whitesport Drive. S.W. in Huntsville and 1701 Main Ave. S.W. in Cullman, plans to meet with patients and their families from 6-8 p.m. Tuesday at Trinity United Methodist Church to discuss anongoing audit of their Medicare accounts by AdvanceMed, a Zone Program Integrity Contractor.
Since January, AdvanceMed has conducted an audit of the pain clinic. Officials were informed in late August that all Medicare payments to the clinic would be suspended while the review continued. Despite presenting evidence that "the clinic has been adhering closely to all appropriate guidelines provided to them by CMS," officials said the outside contractor conducting the audit on behalf of CMS/Medicare chose to stop payments anyway.
The Alabama Pain Center, which receives about 80 percent of its total revenue from Medicare, filed a rebuttal of the auditor's decision to suspend payments in September. The clinic learned last week that CMS/Medicare dropped all but one claim against the pain center but did not lift AdvanceMed's order to stop Medicare payments.
Dr. Dean Willis, chief medical officer and founder of the Alabama Pain Center, said he will continue to appeal the decision, but that process could take more than a year. The Alabama Pain Center, which serves more than 2,700 patients and employs 124 staff members, only has enough reserves to continue operating through November.
"We are bitterly disappointed that this action by CMS and AdvanceMed will force our clinic to close resulting in the inability for our patient's (sic) to receive the care they need," he said in a written statement. "For over 20 years, the one goal of the Alabama Pain Center has been to provide the highest quality state of the art treatments for the thousands of patients who have come to us for help from across our region. It is heartbreaking that this action will no longer allow us to achieve that goal."
Attempts to reach NCI, which acquired AdvanceMed in 2011, on Monday afternoon were unsuccessful. Serving CMS/Medicare since 1999, AdvanceMed is an integrity services provider based in Virginia that works to detect and prevent fraud, waste and abuse in healthcare programs in 38 states.
Willis said Alabama Pain Center patients and staff will continue to work with the Congressional Delegation to stop this decision, and officials are preparing an appeal "based on the danger to life and health that closure of this practice presents to patients." On Tuesday, the Medical Association of the State of Alabama will meet to discuss what options are available to keep the pain center open.
Approximately 322 patients who have received customized spinal medication through the clinic's implantable pain pump therapies will be most affected by the closure.
"They depend on it in order to perform normal daily activities like walk, stand, sit and smile," an announcement said. "These patients are among the most severe of chronic pain sufferers. Each of them have received care from multiple other physician specialists and have tried many other pain therapies, including pain medications, pain blocks, counseling, physical therapy and surgery with no relief."
Willis said the impending closure of the clinic because of a "misguided, bureaucratic review like this" has been upsetting to his staff.
"It is still my hope and my prayer that someone at CMS will put the needs of these patients first," he said. "These patients truly are our family and it is heartbreaking to our entire staff that a misguided bureaucratic review like this can needlessly cause them such pain and suffering. As always, we welcome any audit or review and will participate willingly just as we have done for each of the seven previous reviews. Our desperate plea is for Medicare to allow us to continue the excellent care we have been providing for these past 26 years while this review continues."
During the last five years, the clinic has been audited by three different government agencies or contractors, and none of the reviews resulted in negative findings, the Alabama Pain Center told AL.com in September.