Medicare

More than three dozen just-released audits reveal how some private Medicare plans overcharged the government for the majority of elderly patients they treated, often by overstating the severity of certain medical conditions, such as diabetes and depression.

The federal government released its first overall hospital quality rating on Wednesday, slapping average or below average scores on many of the nation's best-known hospitals while awarding top scores to many unheralded ones.

The Justice Department calls it the largest criminal health care fraud case ever brought against individual suspects: Three people are accused of orchestrating a massive fraud involving a number of Miami-based health care providers.

The three facing charges are all from Florida's Miami-Dade County; they include Philip Esformes, 47, owner of more than 30 Miami-area nursing and assisted living facilities; hospital administrator Odette Barcha, 49; and physician assistant Arnaldo Carmouze, 56, the Justice Department says.

Prescription drug prices continue to climb, putting the pinch on consumers. Some older Americans appear to be seeking an alternative to mainstream medicines that has become easier to get legally in many parts of the country. Just ask Cheech and Chong.

The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases involving denied claims.

The measures "will help us get a leg up on this problem," said Nancy Griswold, chief law judge of the Office of Medicare Hearing and Appeals.

If there weren't a single additional appeal filed and no changes in the system, it would take 11 years to eliminate the backlog, Griswold said in an interview.

A program that has helped seniors understand the many intricacies of Medicare, as well as save them millions of dollars, would be eliminated by a budget bill overwhelmingly approved last week by the powerful Senate Appropriations Committee.

Congress should move to slow spending in Medicare's drug benefit by adopting a package of changes that could save billions of dollars, but that would also add costs for insurers and have mixed effects on enrollees, an independent advisory commission said Wednesday.

Private Medicare Advantage plans treating the elderly have overbilled the government by billions of dollars, but rarely been forced to repay the money or face other consequences for their actions, according to a congressional audit released Monday.

Updated April 20 at 1:50 ET with a statement from the American Hospital Association.

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year's WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare's provider network and she would have to choose new doctors.

"I was terrified," said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.

A diabetes prevention program being tested by the YMCA of the USA has proved successful at reducing the risk of developing the disease, according to the Department of Health and Human Services.

So the Obama administration wants Medicare to pay for the services for beneficiaries at high risk of developing diabetes.

Aetna and Cigna inked deals last month with drug maker Novartis that offer the insurers rebates tied to how well a pricey new heart failure drug works to cut hospitalizations and deaths. If the $4,500-a-year drug meets targets, the rebate goes down. Doesn't work so well? The insurers get a bigger payment.

In another approach, pharmacy benefit firm Express Scripts this year began paying drug makers a special negotiated rate for some cancer drugs. The goal is to reward the use of medicines that are most effective for certain cancers.

Medicare is going to test new ways to reimburse doctors for medications, in hopes they'll choose less expensive drugs.

The plan would alter Medicare Part B, which pays for medicines administered in doctors offices or outpatient hospital clinics — to eliminate incentives for doctors to use the most expensive drugs.

iStock

We’ve been hearing a lot about the politics of health care lately.  In the meantime, many employers are in open enrollment season, making for a confusing month when it comes to health insurance.  And for seniors on Medicare,  November brings the annual dilemma about prescription drugs.