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Group Health Plans Accused of Medicare Fraud

If you live in the Seattle area, you might have seen that Group Health Cooperative (GHC) is under investigation. The nonprofit health insurance company allegedly took advantage of Medicare’s system, stealing millions of dollars to recover from earlier financial losses.

A former employee noticed the company was embellishing patient stories to claim more funds. This extended to even billing Medicare for conditions that were not real.

This all started in 2012 but has remained under lock and key in court until this year. While several employees came forward, the investigation is still in the “ongoing” phase.

Situations like these aren’t isolated.

Almost 20 major cases under Kaiser Health News saw companies skimming off the top of government funds. Medicare Advantage is the easiest tool to do so. All the companies have to do is lie about their patient’s cases, and the money pours in.

face of an insurance building with people walking alongside of it — *Make sure to double-check your information when you give it to your insurance company.*

How It Happened

One employee, Teresa Ross, worked at GHC and noticed the company’s management making some bad choices. Because of these, Group Health saw a drop in operating income by $60 million.

To recover from this, the insurer allegedly took advantage of Medicare’s billing formula. Under Medicare, they give a patient a “risk score.” The higher the risk score, the sicker the patient, and higher-risk patients receive more funds.

GHC hired another company, DxID, to assist with medical charts. With their help, GHC gained $12 million in new claims, and DxID received $1.5 million that year for their assistance.

Ross, with a doctor’s help, reviewed cases GHC oversaw. In the medical coding, she found errors that directly contradicted each other. One case stated the patient had a great disposition, but on further searching, this patient was also billed with having major depression. Clinical depression easily raises a patient’s risk score under Medicare, and this is only one of $35 million in new claims that GHC inflated.

Overestimating these scores, the company received enough funds from Medicare to climb out of their financial hole, but at the cost of government funds allocated to help a sick country–and directly from taxpayers’ pockets. The estimated gross damages climbed up into billions of dollars in just the past few years.

What Happens Next

The Justice Department is investigating this whistleblower case. Like other insurance cases, these last for years in order to provide the most accurate evidence to support such allegations. If Ross succeeds in her case, she will share in reparations the company must make for their actions.

meeting room to discuss medicare fraud — *Investigations take a while for a reason. People just like to make sure justice will be served without any doubt.*

However, the company’s official stance is: “We believe the doing policies being challenged here were lawful and proper and all parties paid appropriately.” GHC’s defense is that Ross found an “honest mistake” and made a bigger conflict out of it than was necessary.

Two conflicting defenses for one stance? For now, we wait for the Justice Department.

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How To Handle Medicare When Moving To Another State

After retirement, some seniors decide to embark on a new challenge: moving. You may want to relocate to a warmer place that is more “senior friendly.” A lot goes into planning when moving, and it can be quite chaotic. One major need is your Medicare coverage. You must notify your Medicare plan providers that you are moving, and then make sure your future doctors in the new state participate with Medicare. Make sure the Social Security Administration is updated as well. Aside from this, it is super important to know that if you are enrolled in a Medicare Supplement plan, your policy price may change depending on where you move to. Do not get stuck with extra charges. Make sure to get it all situated before the move.

Map of the United States — *When you are moving across states lines, it is important to make sure your Medicare plan is updated.*

Original Medicare

Medicare is a federal program and does not change no matter where you move to in America. Medicare Parts A and B do not change. Just make sure before you move, research to find doctors who accept Medicare in the new state.

Medicare Advantage

Medicare Advantage plans have networks depending on the state’s county you live in. You will need to change your Medicare Advantage plan. These plans assign specific doctors through their HMO or PPO plans, so you will have to choose a new plan and a new Primary Care Provider within the plan’s network. Some areas do not even offer Medicare Advantage plans. Notify your current plan before moving.

Medicare Supplement

Medicare Supplement plans help pay for the remaining 20% of the Medicare Part B costs. The plan’s price is determined by your zip code because it varies from state to state. In most states, you can keep your Medicare Supplement plan when you move, but you can apply for a different one if you want. Although you can remain on the same plan, your fees may go up (or down) depending on where you go.

If you do decide to change to a different plan, you might have to go through a health exam, also known as medical underwriting, and the plan may not accept your application. After you are accepted into the new Medicare Supplement plan, you have a “free look period” for 30 days to stay with the new plan. You will, however, have to pay for both plans during the 30-day period. If you decide to keep the new plan, then you can call your old plan and ask

Computer keyboard with a key that says "help" on it. — *If you are stressed out, or do not know where to start, then get help from a Medicare agent.*

for your coverage to be over.

If your Medicare Supplement plan increases when you move to a new state, then you can always contact a Medicare agent to help you search for a more affordable plan. EZ.Insure offers Medicare agents that are trained in your area, and within the state you are moving to. Your personalized Medicare agent will go over your current Medicare Supplement plan to make sure it will be a good fit for you in the new state. If it will be too costly, then our agent will go over all the plans within the new state, compare them, and provide you with quotes. There is no hassle and no obligation. To get started, you can enter your zip code in the bar above, or speak to an agent directly by emailing Replies@Ez.Insure or calling 855-220-1144. We promise to help you find, and sign up with the best Medicare Supplement plan that meets all of your needs within your budget.

Medicare AEP Is Over, What If You Missed It?

Every year from October 15 to December 7 is Medicare’s Annual Enrollment. This is the time you can switch from Medicare to Medicare Advantage, and vice versa. You can also change your Medicare Advantage or Part D plans.

*Just because Medicare OEP is over, does not mean you do not have other options to help you save money.*

Time flies and things happen, and before you know it, open enrollment has ended. You may have not gotten the chance to look over plans, change plans to meet your needs, or did not have enough time to research your options. But luckily if you missed open enrollment, there are still some options for you to choose from.

Medicare Advantage OEP

Beginning 2019, the Medicare Advantage Open Enrollment Period runs from January 1 to March 31 every year. During this period, you can switch Medicare Advantage plans, or disenroll from their Medicare Advantage Plan to Original Medicare. If you choose to switch back to Original Medicare, then you can enroll in a Part D prescription drug plan. Do some research to make sure whichever way to choose to go that the network covers your doctors.

Medicare Special Enrollment Period, SEP

If you missed the open enrollment period, you can qualify for Medicare Special Enrollment Period. Here are the circumstances to qualify for SEP:

- Moved out of plan’s service area

- Lost employer-based health insurance

- Used to be eligible for Medicaid and now you are not

- Your plan is ending its contract with Medicare

Moving back to US after living outside of the US

5 Star Plans

In 2010, the Health care Reform Law created a star rating system for Medicare Plans. One star being poor, and 5 stars being the best. Every fall the ratings are updated for these plans. Beneficiaries can enroll in a Medicare Advantage 5-star plan once a year from December 8 to November 30th.

Medicare Supplement Plans

Medicare Supplement Plans can help you pay for Medicare Part B bills that may be hard for you to pay. These plans are sold by private insurance companies, and you can always consider buying one as long as you are 65 years old. There are 10 different supplement plans to choose from, some covering more than others. If you consider buying one outside of the Medicare Supplement Open Enrollment Period (the 6 month period beginning the month you turn 65), then you may be subject to paying more for pre-existing conditions.

Another option you can take is to ask your doctor for the generic, cheaper brand of the precritions you take.

Change Your Drugs

If you missed the chance to find a better plan to cover your prescriptions, then you can always talk to your doctor about cheaper drug options. The Medicare Modernization Act requires that Medicare offer at least two drugs in each category class. What this means is that you can talk with your doctor and ask to take the alternative drug that costs lower.

Missing the Medicare open enrollment period can cause a lot of stress. EZ.Insure offers agents within your region to help you and answer any questions you may have. Our agents are highly trained to provide you the best option for your needs. The agents will provide you with Medicare Supplement quotes from top carriers in your area, and even help you sign up at no cost. To get quotes, enter your zip code in the bar above, or to speak to an agent directly, email replies@ez.insure, or call 888-753-7207. Do not worry if you missed the OEP, we can help you get on the right track.

Mutual of Omaha Plans To Sell Medicare Advantage Plans in 2019

In 2019, Mutual of Omaha, an Omaha-based insurer will begin selling Medicare Advantage plans with prescription drug coverage. They have partnered up with Lumeris, a St. Louis company that will handle the health provider networks, and healthcare solutions.

The Kaiser Family Foundation recorded that one in three Medicare recipients are enrolled in a Medicare Advantage plan. They project the number to rise to nearly 41 percent by the year 2027.

Omaha is introducing Medicare Advantage Plans in 2019. — *Omaha is introducing Medicare Advantage Plans in 2019 to provide options for seniors.*

The Plan

James Blackledge, the Mutual Chairman and CEO said “Our entrance into the Medicare Advantage market represents a significant step forward for Mutual of Omaha as we strive to respond to customer needs and offer a meaningful suite of senior health solutions. We’re confident that our collaboration with Lumeris will lead to better health outcomes for our Medicare Advantage customers.”

Mutual started in 1909, and has been one of the first providers of Medicare Supplement plans. But recently Medicare Supplement plan sales have been declining, while Advantage sales have increased.

Lumeris has over 10 years of experience with Medicare Advantage plans, even starting their own called Essence Healthcare, which has about 65,000 members in the St. Louis area. They have built a value-based model to provide seniors with better health for a lower cost while providing a better patient and physician experience. The company functions to help other medical providers deliver better care and financial outcomes by its value-based care model.

*The idea is to create more plans so that Medicare beneficiaries can save money, and receive better care.*

“Our new initiative with Mutual of Omaha is exciting because it enables both of our companies to build on our successes while remaining laser-focused on what matters most—delivering the highest quality care to seniors,” said Lumeris Chairman and CEO Mike Long. “This new partnership also leverages each company’s unique strengths to benefit the larger healthcare ecosystem. Together, we will make a deeper, more meaningful difference in the lives of patients and providers.”

Hopeful Future

The alliance between the companies will allow Mutual of Omaha to continue to lead in the senior health market. Mutual will provide Medicare Advantage plans, while Lumeris will evaluate markets, and establish networks.

A Mutual executive vice president, Brad Beuchler said that the plans will have narrow networks. The networks will be limited as to how many physicians, hospitals and care providers to choose from. This way there will be reduced costs while improving efficiency and medical outcomes.

The multiyear agreement is expected to be ready by Medicare open enrollment October 15, and the plans taking effect January 1, 2019. This will hopefully provide better healthcare quality with lower costs for seniors.

Planning Your Medicare Costs During Retirement

Many Americans are turning 65 every day, and can be overwhelmed with the retirement costs to come, especially when unprepared. It is important to plan for retirement and costs for Medicare. Most people underestimate the expenses during retirement. It is important to research medical costs and plan accordingly.

*As you get close to retirement, it is important to plan ahead for monthly Medicare costs. Medicare only covers 60% of costs, consider Medicare Supplement to cover the rest.*

Medicare only covers about 80 percent of costs, leaving retirees to pay the rest out of pocket. Over time, Medicare costs such as premiums will increase over time, so it is important to budget for this.

Find Out Medicare Costs and Additional Insurance

Depending on your preference, there are many possibilities for out-of-pocket expenses regarding your insurance. One of the main payments you will have are Medicare Part B monthly premiums and an annual Part B deductible. The annual deductible is roughly $183, and the monthly premium amount will depend on your income, which is on average $134 a month.

Medicare does not cover prescription drugs or dental and vision care, so if you would like extra coverage and relieve some of the financial burden, many people choose to buy a Medicare Supplemental Insurance or Medicare Advantage.

Long-term care insurance is also something you should consider, considering Medicare does not cover the majority of long-term care costs.

Figure Out Your Medicare Costs

It is important to account and budget for your medical costs within your retirement and social security funds.

*Monthly Medicare Part B Premiums for 2018. See how much your premiums will be.*

Medicare Part B premiums will depend mainly on your income.

There are 10 different kinds of Medicare supplement insurance plans to choose from. It is important to go over each plan, what they cover, and their costs to determine if it will fit within your budget. Plans F and G are typically the most popular because they offer the most coverage with an out of pocket limit. This means once you have reached the out of pocket limit, any other expenses will be covered by the company.

If you are looking into long-term care insurance, it can cost you nearly $100-$150 a month.

Taking all of these costs into consideration is important to determine your retirement costs, and have money left for other living expenses such as food, rent, etc.

Planning your budget during retirement can become very overwhelming. There are many different routes to choose when it comes to your medical needs. EZ.Insure can guide you in the right direction that meets your needs. We can help you estimate your budget and help you determine what you can afford with what you need. We can go over all the different kinds of Medicare Supplement Plans and Medicare Advantage Plans, and when you are ready, we can also help you through the process of signing up.

Enter your zip code in the bar above to get an instant quote. You can reach one of our knowledgeable agents within your region by calling 888-753-7207, or e-mailing replies@ez.insure. Our agents will help you with any questions you have, and guide through the process step by step, all at no cost to you. No commitment, no bouncing from agent to agent, no hassle. We make it easy.

Medicare “Step Therapy” To Lower Drug Costs

Prescription medication can be very expensive, and there is no way around it because it is necessary. However, Medicare has a way to make medication more affordable. The step therapy program allows Medicare to negotiate lower prices and help Medicare beneficiaries save money by offering cheaper medication options.

How Does Step Therapy Work?

Step therapy can be added to your prescription drug plan to offer less expensive medication. The plan will not pay for any of the drugs until you have tried the less expensive ones. It is like a trial and error kind of arrangement.

*Step Therapy offers people less expensive medicine that can be as effective, before having to buy the expensive one.*

First you take the generic form of the medicine, and if it does not work, then the doctor prescribes you another medication. If the second medication does not work, then your doctor will prescribe a different medication that works. However, the medicine that works will be expensive.

Medicare will not pay for the expensive drug unless you go through the step therapy. Once they take a glance and see that you did try the generic forms and they did not work, then they will pay. But if you do not follow the procedure, then the medicine may not be covered, and you will have to pay a lot out of pocket for it.

The CMS has announced that they will be offering the step therapy for Medicare Advantage plans starting January 2019. They estimated that Medicare Advantage beneficiaries spend almost $12 billion a year on drugs. Implementing this procedure will hopefully help control spending, and reduce out of pocket costs.

If you have any questions regarding this procedure, contact your doctor and find out if there are any generic forms of your medication. You can decide if this step therapy is right for you, especially if you are looking to save money. If you have questions or are looking for Medicare help, EZ.Insure is there to help. You will speak to your own knowledgeable agents that are trained for your area. We will go over all the different plans and provide you with quotes. You decide what works for you, and it is all free of charge. Start saving, enter your zip code in the bar above, or contact an agent directly by emailing replies@ez.insure or calling 855-220-1144.