David Hilzenrath and Jodie Fleischer, Cox Media Group
Thu, 30 Nov 2023 18:55:00 +0000

An investigation by KFF Health News and Cox Media Group gained further traction on Capitol Hill this week as additional members of Congress formally demanded answers from the Social Security Administration about billions of dollars it mistakenly paid to beneficiaries — and then ordered they repay.

Two members of a Senate panel that oversees Social Security sent a letter to the agency's acting commissioner, Kilolo Kijakazi, urging her to do more to prevent overpayments and “limit harm to vulnerable beneficiaries” when trying to recover the money.

As KFF Health News and Cox Media Group television stations jointly reported in September, the Social Security Administration routinely sends notices to beneficiaries saying they received benefits to which they weren't entitled — and demanding they pay the government back, often within 30 days.

In the 2022 federal fiscal year, for example, the agency sent overpayment notices to more than 1 million people, Kijakazi told Congress in mid-October.

Alleged overpayments can continue for years before the government notifies a recipient and seeks repayment. By then, the amount a beneficiary allegedly owes the government can reach tens of thousands of dollars or more. People living check to check likely would have spent the money.

To recoup money owed, the government can reduce or stop people's monthly benefit checks.

“[W]e have been deeply concerned by stories from our constituents and recent reports of the extreme financial hardship placed upon beneficiaries who are asked to quickly repay in full or whose payments are halted, reduced, or reclaimed as the agency attempts to correct improper payments, many of which occurred due to agency error,” Sens. Maggie Hassan (D-N.H.) and Bill Cassidy (R-La.) wrote in a Nov. 28 letter to Kijakazi.

Citing the news organizations' reporting, the senators asked what Kijakazi is doing to prevent harm to beneficiaries and what Congress can do.

Hassan and Cassidy are on the Senate Finance Committee's Subcommittee on Social Security, Pensions, and Family Policy.

Meanwhile, Sen. Rick Scott (R-Fla.) sent Kijakazi a letter on Nov. 17 calling the agency's actions “unacceptable.”

“If anyone intentionally defrauded the system or lied to receive payments at other taxpayers' expense, they should absolutely be held accountable and repay this debt to taxpayers,” Scott wrote. “But it's completely wrong for the federal government to go after well-intentioned Americans who did all the right things and trusted that their government was doing the right thing, too.”

Many of the people affected are disabled, low-income, or both and are enrolled in the Social Security Administration's Disability Insurance or Supplemental Security Income programs.

In the 2022 fiscal year, the agency issued an estimated $4.6 billion in SSI overpayments, which represented 8% of payments in that program, according to the agency's latest annual financial report.

Kijakazi recently told a House subcommittee the 8% was “a small percentage.”

In other programs administered by the agency, there were an estimated $6.5 billion in overpayments in fiscal 2022, which amounted to one-half of 1%. Kijakazi called that overpayment rate “extremely low.”

During the 2023 fiscal year, which ended on Sept. 30, the agency recovered $4.9 billion in overpayments, according to a recent statement by Social Security's inspector general. At the end of that period, an additional $23 billion of accumulated overpayments remained uncollected, the statement said.

Since KFF Health News and Cox Media Group TV stations published and broadcast news reports on overpayment clawbacks in September, several members of the House and Senate have written to the Social Security Administration calling for change or answers.

“Many of these overpayment notices come as a complete surprise to SSA beneficiaries, leaving them confused, shocked, and scared that they cannot pay what SSA says they owe,” Rep. Ruben Gallego, an Arizona Democrat and Senate candidate, said in a Sept. 29 letter. “And, because of an indefinite ‘look-back period', SSA can collect funds from a recipient for an error going back decades,” he added.

Asked about the latest letters from lawmakers, Social Security spokesperson Nicole Tiggemann said the agency “will respond directly to the requestors.”

Kijakazi said in October that she ordered a “top-to-bottom” review of how the agency handles overpayments.

Under federal law, the agency must seek recovery of overpaid amounts unless circumstances warrant waiving the debts, Kijakazi said in recent testimony to Congress. There's no time limit on efforts to collect the debts, she said.

In their letter to the acting commissioner, Cassidy and Hassan asked what the agency is doing to make it less burdensome for beneficiaries to appeal or seek a waiver when an overpayment is the government's fault.

In response to questions for this article, Tiggemann, the Social Security spokesperson, said, “We will examine our policies and procedures — including our regulations — to determine where administrative updates to the overpayment recovery and waiver process may reduce the complexity and burden for the people we serve.”

Scott, the Florida Republican, asked if the review Kijakazi announced in October would be disclosed to the public. In a written response to questions for this article, the Social Security spokesperson didn't say.

Do you have an experience with Social Security overpayments you'd like to share? Click here to contact our reporting team.

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By: David Hilzenrath and Jodie Fleischer, Cox Media Group
Title: In Congress, Calls Mount for Social Security to Address Clawbacks
Sourced From: kffhealthnews.org/news/article/social-security-senators-letter-cox-media-group-kff-health-news/
Published Date: Thu, 30 Nov 2023 18:55:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/ftc-chief-gears-up-for-a-showdown-with-private-equity/

Harris Meyer
Thu, 30 Nov 2023 10:00:00 +0000

A recent Federal Trade Commission civil lawsuit accusing one of the nation's largest anesthesiology groups of monopolistic practices that sharply drove up prices is a warning to private equity investors that could temper their big push to snap up physician groups.

Over the past three years, FTC and Department of Justice officials have signaled they would apply more scrutiny to private equity acquisitions in health care, including roll-up deals in which larger provider groups buy smaller groups in a local market.

Nothing happened until September, when the FTC sued U.S. Anesthesia Partners and the private equity firm Welsh, Carson, Anderson & Stowe in federal court in Houston, alleging they had rolled up nearly all large anesthesiology practices in Texas. In the first FTC legal challenge against a private equity purchase of medical practices, the federal agency targeted one of the most aggressive private equity firms involved in building large, market-dominating medical groups.

In an interview, FTC Chair Lina Khan confirmed that her agency wants to send a message with this suit. Welsh Carson and USAP “bought up the largest anesthesiology practices, then jacked up prices and entered into price-setting and market-allocation schemes,” said Khan, who was appointed by President Joe Biden in 2021 to head the antitrust enforcement agency, with a mandate to combat health care consolidation. “This action puts the market on notice that we will scrutinize roll-up schemes.”

The large and growing volume of private equity acquisitions of physician groups in recent years has raised mounting concerns about the impact on health costs, quality of care, and providers' clinical autonomy. A JAMA Internal Medicine study published last year found that prices charged by anesthesiology groups increased 26% after they were acquired by private equity firms.

“Now we're seeing that scrutiny with this suit,” said Ambar La Forgia, an assistant professor of business management at the University of California-Berkeley, who co-authored the JAMA article. “This suit will cause companies to be more careful not to create too much local market power.”

The FTC's lawsuit alleges that USAP and Welsh Carson engaged in an anti-competitive scheme to gain market power and drive up prices for hospital anesthesiology services. The FTC also accuses USAP and Welsh Carson — which established the medical group in 2012 and has expanded it to eight states — of cutting deals with competing anesthesiology groups to raise prices and stay out of one another's markets.

USAP now controls 60% of Texas' hospital anesthesia market, and its prices are double the median rates of other anesthesia providers in the state, according to the lawsuit. Learning that USAP would boost rates following one acquisition, a USAP executive wrote, “Awesome! Cha-ching,” the civil complaint said.

In a written statement, Welsh Carson, which also holds sizable ownership shares in radiology, orthopedic, and primary care groups, called the FTC lawsuit “without merit in fact or law.” It said USAP's commercial rates “have not exceeded the rate of medical cost inflation for close to 10 years.”

The New York firm also said its investment in USAP “has allowed independent anesthesiologists to deliver superior clinical outcomes to underserved populations” and that the FTC's action will harm clinicians and patients. Welsh Carson declined a request for interviews with its executives.

“This is a pretty common roll-up strategy, and some of the big private equity companies must be wondering if more FTC complaints are coming,” said Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. “If the FTC is successful in court, it will have a chilling effect.”

Since the FTC filed the USAP lawsuit, Khan said, the agency has received information from people in other health fields about roll-ups it should scrutinize. “We have limited resources, but it's an area we are interested in,” she said. “We want to focus on where we see the most significant harm.”

In physician acquisition deals, PE firms typically use mostly borrowed money to acquire a controlling interest in a large medical group, pay the physician owners a substantial upfront sum in exchange for sharply cutting their future compensation, and install a management team. Then they seek to acquire smaller groups in the same geographic market and bolt them onto the original medical group for more bargaining clout and operating efficiencies.

The PE firm's goal is to garner at least 20% dividends a year and then sell the group to another investor for at least three times the purchase price in three to seven years. Critics say this short-term investment model spurs the investors and medical groups to boost prices and cut staffing to generate large profits as fast as possible.

“Private equity is trying to extract value quickly and sell the company for a profit, so there's a lot more incentive to increase prices quickly and extract higher revenue,” La Forgia said.

In the two years after a sale, PE-owned practices in dermatology, gastroenterology, and ophthalmology charged insurers 20% more per claim on average than did practices not owned by private equity, according to a JAMA study published last year.

There are similar concerns about hospital systems acquiring physician practices, which also have raised prices. “The evidence shows that both private equity and hospital acquisitions of physician practices are bad for consumers, and scrutiny should be applied to all acquirers,” Adler said.

Critics warn that private equity roll-ups of medical groups can jeopardize quality of care, too. Chris Strouse, a Denver anesthesiologist who served on USAP's national board of directors but left the company's Colorado group out of disapproval in 2020, cited patient safety issues arising from short staffing and mismanagement. He said USAP would schedule shifts so that three or four providers would hand off to each other a single surgical procedure, which he said is risky. In addition, USAP frequently asked anesthesiologists to work the day after working a 24-hour on-call shift, he said. “The literature shows that's outside the safety range,” he said. As a result, many providers have left USAP, he added.

The FTC has long been lax in monitoring roll-ups of physician groups, in part because federal law does not require public reporting of these deals unless they exceed $111.4 million in value, a threshold adjusted over time. Lowering the threshold would require congressional action. As a result, regulators may be unaware of many deals that lead to gradual market concentration, which allows providers to demand higher prices from insurers and employer health plans.

Recognizing that problem, the FTC proposed in June to beef up its reporting requirements for companies planning mergers, in hopes of spotting previous acquisitions of smaller groups that could lead to excessive market power and higher prices. In addition, in a draft of their merger review guidelines, issued in July, the FTC and the Department of Justice said they would consider the cumulative effect of a series of smaller acquisitions.

“The ways PE firms are making serial acquisitions, each individual acquisition is under the radar, but in aggregate they roll up the whole market,” Khan said. “Between the merger reporting form and the new merger guidelines, we want to be able to better catch unlawful roll-up schemes. … This would enable us to stop roll-ups earlier.”

But Brian Concklin, a lawyer with the law firm Clifford Chance, whose clients include private equity firms, said the FTC's proposed reporting requirements would hamper many legitimate mergers. “The notion that they need all that information to catch deals that lessen competition seems overblown and false, given that the vast majority of these deals do not lessen competition,” he said. “It will be a substantial burden on most if not all clients to comply.”

Researchers and employer groups, however, were encouraged by the FTC's action, though they fear it's too little, too late, because consolidation already has reduced competition sharply. Some even say the market has failed and price regulation is needed.

“Providers have been able to extort higher prices on services with no improvement in quality or value or access,” said Mike Thompson, CEO of the National Alliance of Healthcare Purchaser Coalitions. “The FTC stepping up its game is a good thing. But this horse is out of the barn. If we don't have better enforcement, we won't have a marketplace.”

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By: Harris Meyer
Title: FTC Chief Gears Up for a Showdown With Private Equity
Sourced From: kffhealthnews.org/news/article/ftc-chair-lina-khan-private-equity-regulation/
Published Date: Thu, 30 Nov 2023 10:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/uncle-sam-wants-you-to-help-stop-insurers-bogus-medicare-advantage-sales-tactics/

Susan Jaffe
Thu, 30 Nov 2023 10:00:00 +0000

After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency's 24-hour information hotline. Suspects include postcards designed to look like they're from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process.

Insurance companies' advertising campaigns kick into high gear every fall, when seniors can buy policies that take effect Jan. 1. People with traditional government Medicare coverage can add or change a prescription drug plan or join a Medicare Advantage plan that combines drug and medical coverage. Although private Advantage plans offer extra benefits not available under the Medicare program, some services require prior authorization and beneficiaries are confined to a network of health care providers that can change anytime. Beneficiaries in traditional Medicare can see any provider. The open enrollment season ends Dec. 7.

Catching Medicare Advantage plans that step out of line isn't the only reason to keep an eye out for marketing scams. Accurate plan information can help avoid enrollment traps in the first place.

Although insurers and advocates for older adults have generally welcomed the new truth-in-advertising rules, compliance is the big challenge. Expecting beneficiaries to monitor insurance company sales pitches is asking a lot, said Semanthie Brooks, a social worker and advocate for older adults in northeast Ohio. She's been helping people with Medicare sort through their options for nearly two decades. “I don't think Medicare beneficiaries should be the police,” she said.

Choosing a Medicare Advantage plan can be daunting. In Ohio, for example, there are 224 Advantage and 21 drug plans to choose from that take effect next year. Eligibility and benefits vary among counties across the state.

“CMS ought to be looking at how they can educate people, so that when they hear about benefits on television, they understand that this is a promotional advertisement and not necessarily a benefit that they can use,” Brooks said. “If you don't realize that these ads may be fraudulent, then you won't know to report them.”

The agency relies on beneficiaries to help improve services, Meena Seshamani, CMS' Medicare director, told KFF Health News in a written statement. “The voices of the people we serve make our programs stronger,” she said. Beneficiary complaints prompted the government's action. “That's why, after hearing from our community, we took new critical steps to protect people with Medicare from confusing and potentially misleading marketing.”

Although about 31 million of the 65 million people with Medicare are enrolled in Medicare Advantage, even that may not be enough people to monitor the tsunami of advertising on TV, radio, the internet, and paper delivered to actual mailboxes. Last year more than 9,500 ads aired daily during the nine-week marketing period that started two weeks before enrollment opened, according to an analysis by KFF. More than 94% of the TV commercials were sponsored by health insurers, brokers, and marketing companies, compared with only 3% from the federal government touting the original Medicare program.

During just one hourlong Cleveland news program in December, researchers found, viewers were treated to nine Advantage ads.

For the first time, CMS asked insurance and marketing companies this year to submit their Medicare Advantage television ads, to make sure they complied with the expanded rules. Officials reviewed 1,700 commercials from May 1 through Sept. 30 and nixed more than 300 deemed misleading, according to news reports. An additional 192 ads out of 250 from marketing companies were also rejected. The agency would not disclose the total number of TV commercials reviewed and rejected this year or whether ads from other media were scrutinized.

The new restrictions also apply to salespeople, whether their pitch is in an ad, written material, or a one-on-one conversation.

Under one important new rule, the salesperson must explain how the new plan is different from a person's current health insurance before any changes can be made.

That information could have helped an Indiana woman who lost coverage for her prescription drugs, which cost more than $2,000 a month, said Shawn Swindell, the State Health Insurance Assistance Program supervisor of volunteers for 12 counties in east-central Indiana. A plan representative enrolled the woman in a Medicare Advantage plan without telling her it didn't include drug coverage because the plan is geared toward veterans who can get drug coverage through the Department of Veterans Affairs instead of Medicare. The woman is not a veteran, Swindell said.

In New York, the Medicare Rights Center received a complaint from a man who had wanted to sign up just for a prepaid debit card to purchase nonprescription pharmacy items, said the group's director of education, Emily Whicheloe. He didn't know the salesperson would enroll him in a new Medicare Advantage plan that offered the card. Whicheloe undid the mistake by asking CMS to allow the man to return to his previous Advantage plan.

Debit cards are among a dizzying array of extra nonmedical perks offered by Medicare Advantage plans, along with transportation to medical appointments, home-delivered meals, and money for utilities, groceries, and even pet supplies. Last year, plans offered an average of 23 extra benefits, according to CMS. But some insurers have told the agency only a small percentage of patients use them, although actual usage is not reportable.

This month, CMS proposed additional Advantage rules for 2025, including one that would require insurers to tell their members about available services they haven't used yet. Reminders will “ensure the large federal investment of taxpayer dollars in these benefits is actually making its way to beneficiaries and are not primarily used as a marketing ploy,” officials said in a fact sheet.

Medicare Advantage members are usually locked into their plans for the year, with rare exceptions, including if they move out of the service area or the plan goes out of business. But two years ago, CMS added an escape hatch: People can leave a plan they joined based on misleading or inaccurate information, or if they discovered promised benefits didn't exist or they couldn't see their providers. This exception also applies when unscrupulous plan representatives withhold information and enroll people in an Advantage policy without their consent.

Another new rule that should prevent enrollments from going awry prohibits plans from touting benefits that are not available where the prospective member lives. Empty promises have become an increasing source of complaints from clients of Louisiana's Senior Health Insurance Information Program, said its state director, Vicki Dufrene. “They were going to get all these bells and whistles, and when it comes down to it, they don't get all the bells and whistles, but the salesperson went ahead and enrolled them in the plan.”

So expect to see more disclaimers in advertisements and mailings like this unsolicited letter an Aetna Medicare Advantage plan sent to a New York City woman: “Plan features and availability may vary by service area,” reads one warning packed into a half-page of fine print. “The formulary and/or pharmacy network may change at any time,” it continues, referring to the list of covered drugs. “You will receive notice when necessary.”

However, the rules still allow insurers to boast about their ratings from CMS — five stars is the top grade — even though the ratings do not reflect the performance of the specific plan mentioned in an ad or displayed on the government's Medicare plan finder website. “There is no way for consumers to know how accurately the star rating reflects the specific plan design, specific provider network, or any other specifics of a particular plan in their county,” said Laura Skopec, a senior researcher at the Urban Institute who recently co-authored a study on the rating system.

And because ratings data can be more than a year old and plans change annually, ratings published this year don't apply to 2024 plans that haven't even begun yet — despite claims to the contrary.

How to spot misleading Medicare Advantage and drug plan sales pitches (and what to do about it)

The Centers for Medicare & Medicaid Services has new rules cracking down on misleading or inaccurate advertising and promotion of Medicare Advantage and drug plans. Watch out for pitches that:

• Suggest benefits are available to all who sign up when only some individuals qualify.
• Mention benefits that are not available in the service area where they are advertised (unless unavoidable because the media outlet covers multiple service areas).
• Use superlatives like “most” or “best” unless claims are backed up by data from the current or prior year.
• Claim unrealistic savings, such as $9,600 in drug savings, which apply only in rare circumstances.
• Market coverage without naming the plan.
• Display the official Medicare name, membership card, or logo without CMS approval.
• Contact you if you're an Advantage or drug plan member and you told that plan not to notify you about other health insurance products.
• Pretend to be from the government-run Medicare program, which does not make unsolicited sales calls to beneficiaries.

If you think a company is violating the new rules, contact CMS at 800-MEDICARE, its 24-hour information hotline. If you believe you chose a plan based on inaccurate information and want to change plans, contact CMS or your State Health Insurance Assistance Program: www.shiphelp.org or 877-839-2675. For more information about protecting yourself from marketing violations, go to www.shiphelp.org/about-medicare/blog/protecting-yourself-marketing-violations.

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By: Susan Jaffe
Title: Uncle Sam Wants You … to Help Stop Insurers' Bogus Medicare Advantage Sales Tactics
Sourced From: kffhealthnews.org/news/article/medicare-advantage-deceptive-sales-tactics-federal-crackdown/
Published Date: Thu, 30 Nov 2023 10:00:00 +0000