Medicare

 A crackdown on Medicare fraud in South Florida is pushing illegal prescription drug trafficking north, federal investigators told a U.S. Senate Committee.

The Senate Committee on Aging learned that groups are moving north of Miami, the epicenter of prescription drug trafficking, and into the Treasure Coast and Central Florida, the South Florida Sun Sentinel reports..

A new drug hailed as a breakthrough against hepatitis C comes at a price that  puts treatment out of reach for most who need the medication -- $84,000 for a standard 12-week course of Sovaldi, manufactured by Gilead Sciences.

Florida’s Medicare contractor, First Coast Service Options in Jacksonville, recently announced plans to limit coverage for follow-up drug tests, and is accepting public comment.

Federal agencies are teaming up to improve oversight of nursing homes, a practice that now misses a third of the cases of substandard care, according to Kaiser Health News.

The federal government intends to fine Florida for what it describes as a violation of the Social Security Act -- limiting Medicaid patients' emergency room visits to six a year -- the Tampa Bay Times reports.  

In December 2012, the Centers for Medicare and Medicaid Services  rejected the plan from the Florida Agency for Health Care Administration to cap the visits.

The latest delays in implementing the Affordable Care Act are prompting critics to challenge the Obama administration’s legal authority to tweak the law, the Miami Herald reports.

The latest deadline extension, delaying the date for certain employers to offer health benefits to full-time workers, led some Republicans and conservative groups to say it’s a political ploy related to the critical mid-term elections.

Patients who receive treatment at physician practices and outpatient clinics owned by large healthcare companies are being hit by bills for “hospital services,” even though they didn’t set foot in the hospital, the Miami Herald reports. And it’s legal.

Linda Drake, 57, of Miami received a $210 bill after seeing a doctor at an outpatient clinic owned by UHealth, part of the University of Miami. Her private insurer wouldn’t pay it.

A new study shows that critically injured patients with health insurance are more likely to stay put at non-trauma hospitals than be transferred to more skilled facilities, according to Kaiser Health News and NPR.

A federal judge says Florida lost $11 million in 2006 when WellCare executives committed Medicaid fraud, the Tampa Bay Times reports. That amount will influence the sentencing of three WellCare executives who were found guilty in June of Medicaid fraud.  Prosecutors had tried to convince U.S. District Judge James S. Moody Jr.

Federal officials are lengthening a temporary moratorium on new home health care agencies in Miami-Dade and Monroe counties, and have also included Broward County in the ban. As the Miami Herald reports, the six-month ban that starts today is an attempt to deter Medicare and Medicaid fraud. Federal health officials say Miami-Dade has the highest ratio of home health agencies to Medicare beneficiaries and has the biggest payments.

Denial of benefits and confusion over out-of-pocket costs top the list of complaints to a Medicare consumer help line, according to a report cited in the Tampa Bay Times.

The report was based on more than 14,000 calls in 2012 to the Medicare Rights Center, a non-profit advocacy group. The center said denial of benefits -- in which the federal agency declines to pay a claim -- accounted for 33 percent of the calls.

The Office of Medicare Hearings  and Appeals, which is overwhelmed, has decided to bring the cases filed by beneficiaries to the front of the line. That means appeals by hospitals, nursing homes, doctors and other health-care providers could be on hold for two years.

Following the example of private companies, Medicare is moving to limit the number of drug brands it will cover. The Centers for Medicare and Medicaid Services have proposed to allow private prescription-drug plans under Medicare Part D to cover only some of the antidepressants on the market, not all, according to the South Florida Sun Sentinel.

The owner of a South Florida clinic has pleaded guilty to defrauding Medicare to the tune of almost $20 million, the Associated Press reports. Isabel Medina could face 10 years in prison for her role in several health schemes.

 

MIAMI - A South Florida woman has pleaded guilty to involvement in several health care fraud schemes that cost the Medicare program an estimated $20 million.

Former Merfi Corp. clinic owner Isabel Medina pleaded guilty Tuesday in Miami federal court to health care fraud conspiracy, which carries a maximum 10-year prison sentence. The 49-year-old Medina will be sentenced in March.

PolitiFact

The claim from the former director of the Office of Management and Budget that Medicare spending fell between 2012 and 2013 is true, according to PolitiFact.

Twelve Florida hospitals had outcomes significantly better than average on results for hip and knee replacement operations in the past three years, according to Medicare data published on the Hospital Compare website.

Three of them scored significantly better than average on both the rates of complications and re-admissions, the two categories analyzed. They are Heart of Florida Regional Medical Center in Davenport, Holy Cross Hospital in Fort Lauderdale and Ocala Regional Medical Center.

A West Palm Beach eye doctor’s patients call him a  "miracle worker" for using cutting edge medicine to preserve their vision.  But the FBI and Department of Health and Human Services have a different view of Dr. Salomon Melgen, according to the Miami Herald.  Melgen, a close friend of U.S. Sen. Bob Menendez, D-N.J., has seen his offices raided twice this year, as part of a Medicare fraud investigation.

Carol Gentry

On Jan. 1, hundreds of Florida doctors who now treat UnitedHealthcare's Medicare patients will be dropped. A host of patients have been affected nationwide. (See update: FMA Protests Doctor-Dropping)

Yoselis Ramos / WUSF

If you weren't looking for it, you might miss it, sitting between a nail salon and a discount grocery store in a shopping plaza that seems to have an endless parking lot. Tucked in the plaza is a multi-million dollar medical clinic. 

"The model is all inclusive, where you can come and get everything taken care of in one place," said Mark Kent, CEO of CAC-Florida Medical Centers, a subsidiary of health insurance giant Humana.

What's Best Value in Medicare Plan?

Dec 3, 2013

Even when a Medicare Advantage plan wins the federal top-quality 5-star rating, it isn’t necessarily the right choice for every beneficiary, according to a cost-sharing analysis from HealthMetrix Research.

Per-person Medicare spending, much higher in Florida than all but one other state, has seen a dramatic increase in "post-acute" services -- nursing homes, home-health services, rehabilitation, and so on. And there is no rhyme or reason to the spending; patients who are much alike may be sent to nursing homes in one region, sent home in another. 

A judge has ruled that a Daytona Beach hospital violated the federal Stark Law, which bars physicians from getting extra cash from patient referrals through kickbacks, split fees and other under-the-table arrangements, the Orlando Sentinel reports.

The case, scheduled to go to trial in March, stems from a 2009 lawsuit filed by whistleblower Elin Baklid-Kunz, a former compliance officer for Halifax Hospital.  Hospital officials have denied wrongdoing.

Tampa-based WellCare Health Plans Inc. is planning to borrow $600 million, the Tampa Bay Business Journal reports. The company, which provides managed care services for Medicaid and Medicare health plans, will issue senior notes in a public offering.

A 40-something patient I'll call Ted has a list of conditions that would have tongue-tied Carl Sagan. Even though I see Ted in my clinic every month, he still winds up visiting the emergency room 20 times per year.

Yes, 20.

Before he became my patient, he went even more frequently. So, the current situation, bad as it may be, represents halting progress.

Lottie Watts/WUSF / WUSF

More than half of the Medicare Advantage plans available for enrollment now in Florida for 2014 coverage earned a rating of at least four stars out of five, according to data organized by Avalere Health

Four Florida plans -- all sponsored by Cigna -- earned the coveted five-star rating: three plans in Bay County and one in Miami-Dade. There were no five-star Advantage plans available in 2013 anywhere in Florida.

Lottie Watts / WUSF

It's open enrollment season for Medicare, the time when beneficiaries can switch plans if they want. Plenty of private insurance companies are competing to enroll them in Medicare Advantage plans.

If you have Medicare, or you're getting close to age 65, your mailbox is likely overflowing with offers. The ads are coming at you on TV, too. 

George Washington University

Many have grumbled about it before, but now it's been officially noted in the nation's top health-policy journal, Health Affairs: Florida gets shortchanged when it comes to graduate medical education funding from Medicare. And it's not the only one.

John Pendygraft / Tampa Bay Times

UnitedHealthcare’s AARP Medicare Advantage plan is dropping thousands of physicians from its network, as well as extras like fitness classes through Silver Sneakers, the Tampa Bay Times reports (paywall alert). In the words of one beneficiary whose plan will soon stop paying for aqua aerobics classes at the YMCA, the change in benefits is “pretty dumb.” 

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