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U.S. can sue UnitedHealth in $1 billion Medicare case, judge rules

(Reuters) – A federal judge has ruled the U.S. Justice Department can move forward with a lawsuit claiming UnitedHealth Group Inc wrongly retained more than $1 billion from the government healthcare programme Medicare.

U.S. District Judge Michael Fitzgerald in Los Angeles on Monday ruled that the department had sufficiently alleged UnitedHealth submitted invalid diagnostic data related to the health status of patients enrolled in Medicare Advantage plans.

But Fitzgerald dismissed claims that the insurer falsely attested to the data’s validity, saying the key allegation that those assurances affected payment decisions by the U.S. Centers for Medicare and Medicaid Services was “missing.”

Fitzgerald said that while the data itself appeared to be material to the agency’s payment decisions, the allegations regarding the assurances UnitedHealth made about the data “do not suggest they are likely to influence the payment of money.”

UnitedHealth in a statement on Tuesday said it rejects the Justice Department’s remaining claims and will continue contesting them. The Justice Department had no immediate comment.

Fitzgerald’s decision to dismiss part of the case was based on a 2016 U.S. Supreme Court decision regarding what must be alleged under the False Claims Act to prove a company’s false statement was material to the government paying it.

That law allows the government and whistleblowers suing on its behalf to recover taxpayer money paid to companies based on fraudulent claims.

If successful, whistleblowers receive a percentage of the recovery. The government may intervene in whistleblower lawsuits, typically a major boost to those cases.

Last year, the Justice Department intervened in a lawsuit brought by former UnitedHealth executive Benjamin Poehling, whose whistleblower case was filed under seal in 2011.

The Justice Department said UnitedHealth obtained inflated risk adjustment payments based on untruthful and inaccurate information about the health of patients enrolled in Medicare Advantage plans.

More than one-third of Medicare recipients are in Advantage plans run by private insurers like UnitedHealth.

The lawsuit said UnitedHealth failed to repay the Medicare programme by over $1.14 billion from 2011 to 2014.

The case was one of two that the Justice Department announced last year against UnitedHealth related to payments it received for patients enrolled in Medicare Advantage plans.

But a federal judge in October dismissed the other case, saying the government failed to allege CMS would have refused to make payments to UnitedHealth if it had known all the facts.

The case is U.S. ex rel. Poehling v. UnitedHealth Group Inc et al, U.S. District Court, Central District of California, No. 16-cv-08697.

Reporting by Nate Raymond in Boston; Editing by David Gregorio


CMS: Increased Medicare enrollment a major driver behind healthcare spending trends over next decade

Healthcare spending growth grew at a slightly faster rate in 2017, reaching nearly $3.5 trillion, and Medicare spending is expected to climb substantially over the next decade as more baby boomers qualify for coverage, according to new estimates from the Centers for Medicare & Medicaid Services.

CMS’ Office of the Actuary estimates that healthcare spending increased by 4.6% last year, a slight faster growth rate than the 4.3% recorded in 2016, according to its annual health expenditures projections, which were published in Health Affairs. Between 2017 and 2026, the actuary projects spending to increase by 5.5% on average each year, with total spending reaching $5.7 trillion by 2026. 

CMS suggested in its report last year that growth in healthcare spending would overtake growth in the U.S. gross domestic product, and that estimate holds true for 2017 to 2026, as well, according to the report. It estimates that growth in healthcare spending will outpace GDP growth by one percentage point over the next decade, and expects healthcare spending to account for 19.7% of U.S. GDP by 2026. 

One of the major drivers of healthcare spending trends over the next decade is the aging population, Gigi Cuckler, an economist with the Office of the Actuary’s National Health Statistics Group and one of the report’s lead authors, said at a press briefing Wednesday. 

“It’s very clear that the aging population has a significant impact on enrollment in Medicare and a shift out of private insurance,” Cuckler said. 

The actuary’s report also projects that healthcare costs will grow at a slightly faster rate, further driving growth in healthcare spending. CMS has accounted for some changes from the Republicans’ tax reform legislation but did not calculate the impact of the bipartisan spending deal passed last week. 

New from @CMSGov actuaries: National Health Spending Projections 2017-2026

— Health Affairs (@Health_Affairs) February 14, 2018

As Medicare enrollment increases, Medicare spending will increase in tandem, according to the report. The actuary estimates that Medicare spending will grow by an average of 7.4% each year through 2026. 

Slower spending growth is expected in private insurance as more baby boomers qualify for Medicare and people with private insurance use less care. Spending in private insurance is expected to grow by 4.7% per year between 2017 and 2026, a growth rate that is slowing in part as more people enroll in high-deductible health plans, according to the report. People enrolled in high-deductible plans through their employers are more likely to skip on healthcare, including preventive screenings that are required to be free under the Affordable Care Act.

CMS also projects that the repeal of the individual mandate will play a role in lowering spending for private insurance. The report estimates that the number of people with health insurance will dip by 2026, decreasing from 91.1% in 2016 to 89.3%. The report projects that some people will choose to forgo insurance without the penalty in place.

The actuary assumes “that some younger and healthier people will choose to be uninsured—particularly those with comparatively higher incomes who might not qualify for premium subsidies in the health insurance marketplaces,” according to the report.

An area where CMS expects to see some of the highest spending growth is in prescription drug spending, which it projects will grow by an average of 6.3% per year over the next decade. One of the major drivers of this trend is the growing cost of drugs, which the Office of the Actuary expects to compound in the latter years of the projection window because of pricey specialty drugs. 

Sean Keehan, another economist in the Office of the Actuary and one of the report’s authors, said at the briefing that CMS expects to see generic drugs serving as less of a mitigating factor on the rising cost of brand name and specialty medications. 

“The dollar value of drugs going generic is projected to be less of a factor in 2018 than 2017,” he said. “Price increases in brand name drugs won’t be mitigated by some drugs going generic.”

CMS also expects rebates to have less of an impact on lowering the cost of drugs in the coming years compared to years prior, Keehan said. 


Trump Is Coming for Medicare, Medicaid and the ACA

Photo by Chip Somodevilla/Getty Images

President Trump released his 2019 budget vision today, and as you might expect it proposes some deep cuts to domestic programs while ratcheting up military spending and allocating $18 billion over the next two fiscal years for The Wall, while adding $984 billion to the federal deficit next year.

There’s a lot to take in, but one part that stuck out to me about the proposal, titled “Efficient, Effective, Accountable: An American Budget,” is the call for cuts to Medicare, Medicaid and the Affordable Care Act. It also proposes cutting the Supplemental Nutrition Assistance Program by $214 billion over 10 years.

During the election, Trump repeatedly said he wouldn’t touch the big three publicly funded programs, tweeting a bunch of times, and saying it in speeches. And for good reason: Medicare is popular, and as medical costs continue to balloon, it will only be more so. In fact, “Medicare for All,” a dream of the left, is itself picking up popularity.

At this point, it’s hard to be surprised by anything Trump does or says. But his new budget calls for steep cuts to Medicare spending—$554 billion over 10 years—in part to offset the $1.4 trillion in tax cuts he and the GOP gave away largely to corporations and the rich this year. The proposal says it would do this “without harming beneficiaries’ access to care or altering covered items and services,” but instead by eliminating federal waste, and by changing what is known as the “doughnut hole” in prescription drug plans. “Far fewer people would reach the catastrophic phase, where they pay 5 percent of the drug cost—and where Medicare is on the hook for 80 percent,” reports .

It’s true that this budget plan has little chance of coming to fruition (Congress will make the final spending decisions, in part passed last week and signed by Trump), and that the president proposed similar cuts in last year’s budget, but it does make clear the president’s priorities, which, if it wasn’t obvious yet, have not been to help struggling Americans.

What You Need to Know About the Budget Deal

Congress managed to pass a budget deal early Friday morning after a brief government shutdown,…

The budget calls for a “market-based health-care grant” that would pay for programs “in addition to the traditional Medicaid program, a change that would lower Medicaid spending by about $250 billion over 10 years,” WaPoreports, and again calls for the repeal and replace of the ACA, which expanded health insurance coverage to 20 million more Americans, about 14.5 million of whom gained coverage via the Medicaid expansion or through the Children’s Health Insurance Program.

The budget bases this on the supposed failure of the law: “For 2018, approximately 30 percent of enrollees only had choices from a single insurer. The Exchanges have not done enough to attract healthier individuals and families that want affordable options that meet their needs.”

There is much to be said about fixing the ACA, but using increased premiums and fewer options as the justification for scraping the law is questionable. The Trump administration has done everything it can to hinder the ACA’s implementation and efficacy, including running negative ads about it, cutting spending on advertisements for open enrollment, and forcing through a repeal process in 2017 that left millions unsure whether they’d have health care in the new year. Insurers, the Congressional Budget Office and independent analyses said that the uncertainty surrounding the law, created by the administration’s actions, were to blame for the jump in prices and lower competition.

So it’s not surprising that premiums were up (though the budget, oddly, does not explain that subsidies—which around 85 percent of Obamacare enrollees qualify for—would offset those increases). What is surprising is that it wasn’t worse.

Here’s the budget in full.


Trump’s budget could let those on Medicare use this tax-favored account

  • Budget proposal would let Medicare beneficiaries contribute to health savings accounts.
  • Retiree healthcare costs could hit $275,000 per couple, excluding long-term care expenses.

A provision tucked in President Donald Trump’s proposed budget would give people on Medicare a way to save for health care costs on a tax-advantaged basis.

In the proposal , the White House calls for a new option that would permit Medicare beneficiaries to make tax-deductible contributions to health savings accounts.

That’s a shift from today’s law, as the IRS doesn’t allow those on Medicare to contribute to HSAs, and the proposal offered few details as to how this would work. It’s also unclear whether this provision will be supported in Congress, which ultimately controls the purse strings.

Here’s what the proposal may mean for your ability to pay for retirement health care costs.

Health savings accounts have a triple-tax benefit.

That is, they allow insured individuals to save money on a tax deductible or pre-tax basis. Contributions grow free of taxes, and account holders may make tax-free withdrawals as long as the money goes toward qualified medical expenses.

This year, HSA holders can sock away up to $3,450 if they have single insurance coverage, while those with family coverage may save up to $6,900.

Those over 55 can save an additional $1,000 each year.

It’s unclear what the limits would be for Medicare beneficiaries if adopted.

Unused HSA balances roll over into the following year.

As of 2016, more than 20 million people were enrolled in high-deductible health plans with HSAs, according to America’s Health Insurance Plans, a trade association that represents insurance companies.

While HSA holders who are on Medicare can’t make contributions under current law, they can still tap their savings for qualified medical costs in retirement.

HSA users can leverage their accounts in one of two ways : Either they pull money from the account to cover ongoing health expenses, or they cover those expenses out of pocket and allow the HSA to accumulate over time.

You can strengthen your HSA’s growth potential by contributing to the account over the long term, and investing your contributions into mutual funds or exchange traded funds , if they’re available at your provider.

Given enough time to grow, an HSA can be an additional pot of assets in retirement : You can use them to cover qualified medical expenses, including certain long-term care services .

Consider allowing your account to grow, as a couple’s retirement healthcare costs can run as high as $275,000, according to Fidelity. That figure excludes the cost of long-term care.

Be aware of the consequences that may come up if you die while holding an HSA: If your spouse is the designated beneficiary, then the IRS treats the account as though it belongs to him or her.

If someone else is the beneficiary of the account, then the account is no longer an HSA and its fair market value becomes taxable to the recipient in the year you die.

If you’ve maxed your 401(k), here’s another way to save big Don’t let money in your flexible spending account go to waste Beware, there’s a new wave of Medicare scammers


Navigating Medicare: 5 allies who can help

(BPT) – Enrolling in Medicare for the first time or starting coverage under a new plan? It might bring you back to that first day starting a new job. You knew some of the basics, but you also knew there was a lot more to learn. More than likely, you got help from colleagues who have been around for a while and helped show you the ropes.

Don’t worry. With Medicare, you have the same kind of knowledgeable support. You’ve got a team on your side that can help make navigating the health care system easier. Goodbye hassles, hello helpers.

Here are five allies in your corner:

1. Your Primary Care Physician. This physician is the “go-to” doctor who provides guidance on your health care needs, taking the time to really get to know you, your medical history and your health goals. Think of your Primary Care Physician as the “quarterback” of your medical team — someone who can take charge of knowing the ins and outs of your health status and help drive decisions to get you on the right track and keep you there.

2. A caregiver. Perhaps the “unsung hero” of your health care team, caregivers are the ones you know you can count on — the ones you know are there to offer support and care for you, whenever you need it. Whether a family member, neighbor, friend or professional assistant, these are the people in your life who help you along the way. Their assistance can span everything from bringing you to appointments or getting prescriptions filled to making meals or offering emotional support.

3. Your pharmacist. This team member keeps an eye on the medications you take — prescription and over-the-counter — to make sure they work safely together. Your pharmacist is a great person to talk with about how medications are making you feel and answer any questions you have on topics including what side effects to expect, what to do if you miss a dose, or how to store your meds.

4. An insurance agent. Original Medicare. Medicare Supplement. Part D. Medicare Advantage. There are many options and decisions to make when it comes to your Medicare coverage, and a licensed insurance agent can help you find the right plan, or plans, for you. Once you’ve selected a plan, you can also always call your agent to ask questions if your health or coverage needs change or if your plan changes from year to year.

5. Your insurance company. Within your insurance company, there are more people than you likely realize who are working hard on your behalf to ensure you get the medical care and support you need. Insurers can offer tools, resources and support that can help you live a healthier life.

For more information to help you navigate Medicare, visit


Congressional support for Medicare Advantage pivotal

Medicare Advantage for 2018. This decision is expected by the end of March.

Congressman Charlie Dent showed his support for Medicare Advantage by recently signing on to a bipartisan House letter asking to “protect and preserve” funding for Medicare Advantage.

Last year I turned 65. I spent many hours studying and understanding the pros and cons of health care coverage under Medicare, Medicare Advantage and Medicare Supplemental. For my situation, Medicare Advantage was far and away the best coverage for the best value.

I certainly recommend Medicare Advantage but the bottom line is having the choice. Seniors should have options for health care so they can select the plan that works best for their situation.

I’m glad our Congressman Dent joined his colleagues in underscoring the many upsides of Medicare Advantage. This support means the program and the choices it offers seniors will continue to thrive.