Skilled nursing operators should expect continued documentation scrutiny and payment integrity efforts from both regulators and MA plans.
Medicare Advantage Fraud: Insurer to Pay $100M in Settlement
A western New York health insurance provider for seniors and the CEO of its medical analytics arm have agreed to pay a total of up to $100 million to settle Justice Department allegations of fraudulent billing for health conditions that were exaggerated or didn’t exist.
Independent Health Association of Buffalo, which operates two Medicare Advantage plans, will pay up to $98 million. Betsy Gaffney, CEO of medical records review company DxID, will pay $2 million, according to the settlement agreement. Neither admitted wrongdoing.
In settling fraud case, New York Medicare Advantage insurer, CEO will pay up to $100M
— KFF Health News, December 20, 2024Medicare Advantage provider Independent Health to pay up to $98m to settle False Claims Act suit
— US Justice Department, December 20, 2024Medicare Advantage insurer to pay up to $98M to settle false claims allegations.
— Becker’s Payer News, December 23, 2024
Nursing Home Providers Adjust to Optum Exiting Medicare Advantage I-SNPs in Several Regions
Optum is scaling back its Medicare Advantage Special Needs Plans for nursing home and assisted living residents in several regions.
The health care services arm of insurance giant UnitedHealth Group (NYSE: UHG), Optum, made headlines earlier this year for workforce cuts. Now, the company is shutting down Institutional Special Needs Plans (I-SNPs) in several states, multiple sources told Skilled Nursing News.
— Skilled Nursing News, November 5, 2024
UnitedHealth Study: Is Medicare Advantage Killing Seniors.
In “Home Health Cuts and Barriers are Life and Death Issues for Medicare Beneficiaries,” Dr. Landers points readers toward a study conducted by Dr. Elan Gada of UnitedHealthcare’s Optum Group. The results are disturbing. That the findings were released by a Medicare Advantage company is surprising.
Yes, Virginia, Home Healthcare Really Does Save Lives
Landers cited the study’s primary finding. “Medicare Advantage beneficiaries in their plan who did not receive needed home health care after hospitalization were 42% more likely to die in the 30 days following a hospital stay than those who received the prescribed care.” If a drug proved to be as effective as post-discharge home healthcare in saving lives, Landers wrote, “it would dominate the news, restricting access would be considered immoral, and health officials would be pushing its adoption.”— The Rowan Report, October 31, 2024
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