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Sabtu, 20 September 2014

Medical Records For Sale Found On the Black Market - Evolution Market Where Narcotics And Stolen Financial Data Is Openly Traded and Sold…

This was not from a healthcare company, but rather a life insurance company in Texas.  The fact of the matter here is that there’s enough in there for thieves to make a sale, and another and another.  The story mentions the TOR browser and if you don’t know what it is,image it’s a fork of Firefox that allows form anonymous browsing and actually the only way the Evolution Market can be browsed.  Tor is a legal browser and government agencies, reporters, etc. all use it and it’s just like anything else out there used for the good or the bad. 

What’s interesting here is the terminology the author tells us about as this is something new for me to be reading about.  So now if you hear the word “fullz” you know the street slang here means it’s a load file of all kinds of personal and financial records.  All purchases are done via bitcoin which is kind of bad as it give bitcoin a bit of a bad association.  You can read the article below and see the more you buy, the better the price break too. 

By the time this information was related the government had just begun working on the problem.  The dates on the postings and files seemed to indicate the records had been on sale for around 3 months.  One of the victims now is also complaining about the numerous calls she’s now getting over and over about the theft and saying the notification calls are a bit over done too.   As Dr. Halamka at Harvard recently said, it’s become a war keeping patient medical records secure from hackers. 

It’s Become A war To Keep Patient Medical Records Secure And Out of the Hands of Hackers, Data Selling Epidemic in the US Fuels This Fire…

One of the comments in this article too was very astute in asking “I tend to wonder how many “legitimate” companies are buying these data.”  That comes right back around to the need to license all data sellers in the US.  Let’s revisit the Game Data Dealer here just for the heck of it..they do a good job with dramatics to get your attention.  BD  

Two Data Brokers Get Fined by the FTC For Non Compliance, One Gets Most All Of The Million Dollar Fine Reduced as They Could Not Afford To Pay By the Court, But If You Are A Consumer With Medical Bills You Go To Bankruptcy Court..


How much are your medical records worth in the cybercrime underground? This week, KrebsOnSecurity discovered medical records being sold in bulk for as little as $6.40 apiece. The digital documents, several of which were obtained by sources working with this publication, were apparently stolen from a Texas-based life insurance company that now says it is working with federal authorities on an investigation into a possible data breach.

Purloined medical records are among the many illicit goods for sale on the Evolution Market, a black market bazaar that traffics mostly in narcotics and fraud-related goods — including plenty of stolen financial data. Evolution cannot be reached from the regularimage Internet. Rather, visitors can only browse the site using Tor, software that helps users disguise their identity by bouncing their traffic between different servers, and by encrypting that traffic at every hop along the way.

Last week, a reader alerted this author to a merchant on Evolution Market nicknamed “ImperialRussia” who was advertising medical records for sale. ImperialRussia was hawking his goods as “fullz” — street slang for a package of all the personal and financial records that thieves would need to fraudulently open up new lines of credit in a person’s name.

Each document for sale by this seller includes the would-be identity theft victim’s name, their medical history, address, phone and driver license number, Social Security number, date of birth, bank name, routing number and checking/savings account number. Customers can purchase the records using the digital currency Bitcoin.

A set of five fullz retails for $40 ($8 per record). Buy 20 fullz and the price drops to $7 per record. Purchase 50 or more fullz, and the per record cost falls to just $6.40 — roughly the price of a value meal at a fast food restaurant. Incidentally, even at $8 per record, that’s cheaper than the price most stolen credit cards fetch on the underground markets.

“Live and Exclusive database of US FULLZ from an insurance company, particularly from NorthWestern region of U.S.,” ImperialRussia’s ad on Evolution enthuses. The pitch continues:

“Most of the fullz come with EXTRA FREEBIES inside as additional policyholders. All of the information is accurate and confirmed. Clients are from an insurance company database with GOOD to EXCELLENT credit score! I, myself was able to apply for credit cards valued from $2,000 – $10,000 with my fullz. Info can be used to apply for loans, credit cards, lines of credit, bank withdrawal, assume identity, account takeover.”

Sure enough, the source who alerted me to this listing had obtained numerous fullz from this seller. All of them contained the personal and financial information on people in the Northwest United States (mostly in Washington state) who’d applied for life insurance through American Income Life, an insurance firm based in Waco, Texas.

American Income Life referred all calls to the company’s parent firm — Torchmark Corp., an insurance holding company in McKinney, Texas. This publication shared with Torchmark the records obtained from Imperial Russia. In response, Michael Majors, vice president of investor relations at Torchmark, said that the FBI and Secret Service were assisting the company in an ongoing investigation, and that Torchmark expected to begin the process of notifying affected consumers this week.

More than 1.8 million people were victims of medical ID theft in 2013, according to a report from the Ponemon Institute, an independent research group. I suspect that many of these folks had their medical records stolen and used to open new lines of credit in their names, or to conduct tax refund fraud with the Internal Revenue Service (IRS).

http://krebsonsecurity.com/2014/09/medical-records-for-sale-in-underground-stolen-from-texas-life-insurance-firm/

Jumat, 19 September 2014

Erlanger Health System in Tennessee Looking to Cut Ties With United Healthcare–Contract Expires at the End of the Month

As you can read below there’s a lawsuit that’s pending regarding payments filed by the hospital a few years ago.  Basically the hospital is saying they are not paying adequately.  All physicians would be out of network and again would this be a double whammy for the Medicareimage Advantage patients, some of which have already had their primary doctors fired.  If you read the link below you can see where United is working to match patients up with new doctors but the algorithms are doing funny things and giving patients OBGYNs and Neurosurgeons as their new primary care MDs. 

Patients In Tennessee Speak Out About United Healthcare Firing Their Doctors As the Effort Continues To Reduce Their Own In House Overhead With Managing Fewer Doctor NPI Accounts, Contracts and Billing…More Killer Algorithms At Work Hurting Seniors

A couple more weeks and we shall see if they walk away from the Medicaid contract and the rest that also follows.  BD 


The Chattanooga region’s largest hospital system may soon be out of network for thousands of patients with UnitedHealthcare insurance if a bitter dispute with Erlanger Health System over payment rates is not resolved by the end of the month.

Erlanger officials say the current dispute, which centers on a contract with United’s Medicaid product, is the final straw in a long-strained relationship between the public hospital and the for-profit insurer.

If a deal is not reached, children and pregnant mothers who have United insurance through TennCareimage will be out of network on Oct. 1. Erlanger has the area’s only children’s hospital.

But Erlanger officials say the partnership has never been smooth.

“No other insurer has been this difficult to work with,” Erlanger CEO Kevin Spiegel said.

For patients who have United insurance through their employers or through Medicare Advantage, Erlanger would be out of network as of Jan. 1, 2015. That would include all of Erlanger’s affiliated physician groups and community health centers.

United has been paying “pennies on the dollar” of what should be standard for its TennCare patients, Erlanger argues, and repeatedly denies the hospital’s claims. The hospital sued United over this issue five years ago, and the litigation is ongoing.

Hospital officials say they made an offer that was about 75 percent of the highest possible reimbursement. United rejected it.

Erlanger is the third-largest TennCare provider in the state, and takes the highest percent of TennCare patients in the region.

“They are willing to walk away from the entire Medicaid population in East Tennessee,” Spiegel said.

United’s gross profit from TennCare was nearly $422 million in 2013 and $490 million in 2012, according to an equities analysis by CitiBank.

http://www.timesfreepress.com/news/2014/sep/18/erlanger-looking-cut-ties-united-healthcare/?breakingnews

Selasa, 16 September 2014

Anthem Blue Cross Creates Yet One More New Insurance Plan–Vivity, Partnering With 7 Major Hospitals in Los Angeles

Well did they did one thing right and got CalPERS on board so that a lot of business to start out with effective January 1, 2015.  CalPERS was just in the news with getting rid of all their hedge fund investments to the tune of $4 billion as well.   MemorialCare andimage Cedars already have a few things going together like this Venture Capital fund created a few months ago. 

Cedars-Sinai and MemorialCare Health System Create New Venture Capital Company-Sounds Like A Little Influence of From The United Healthcare Manifesto Is Moving Up to LA, Maybe More Cash For Code for Developers?

The whole idea here is to take on Kaiser as they have a lot of business and are self contained with both insurance and medical care in one.  It will be called the Vivity Health Plan and will be about 10 percent less in cost than a standard Anthem Blue Cross HMO plan.  Nobody knows if this will save any money or not and right now in that area it’s just a proof of concept.  There will be around  6000 doctors and 14 hospitals all together in the group.  Already with UCLA and Cedars they both invested in a rehab hospital so they can move you over to the old Century City Hospital to get you out the door faster.

Century City Hospital In West LA To Get a New Life, A Rehab Hospital Investment For UCLA and Cedar Sinai Hospitals

This probably explains the madness behind the new big data base Blue Cross is paying $80 million to start as well and I have no clue on how it will work and have my doubts on that one as well unless now these hospitals decide to kick in for an HIE type of operation.

Anthem Blue Cross & Blue Shield of California Going to Create “Yet Another Big Data Base of Patient Medical Records” - Be Ready for Premiums to Go Up As Health IT Eats Up the Healthcare System

Also I would imagine the $350 a month kick back to the Oncologists will play in here too with all the doctorsimage seeing cancer patients where they agree to use the Blue Cross methods of recommended treatment.  Anthem Blue Cross is a licensed reseller of IBM Watson and a couple years ago pretty much foot the bill for the use at Cedars to get it started.

WellPoint Begins New Oncology Program For Providers Offering Doctors $350 Monthly Payment For Each Patient Treated Using Insurers Recommendations - Is This A Kickback Offer?

I can understand what they are doing here and at least they are being honest and saying “this is just a stab in the dark” venture.  Obviously having CalPERS as base is big help by all means if a great number of their insured sign up.  This will get interesting as there will be one more plan to check eligibility with.  This gets kind of interesting as MemorialCare in more ways than one has some pretty strong ties to United Healthcare too.  MemorialCare owns the management company that runs the Cedars Doctor’s IPA group, Nautilus, which also runs Greater Newport Physicians in the OC.   BD   


Taking aim at HMO giant Kaiser Permanente, insurer Anthem Blue Cross is joining forces with several big-name hospitals and their doctors to create an unusual health plan option for employers in Southern California.

The joint venture being announced Wednesday brings together seven rival hospital groups in Los Angeles and Orange counties, including well-known institutions Cedars-Sinai Medical Center and the UCLA Health System. The deal reflects the pressure insurers and hospitals alike are facing to hold down healthcare costs for employers and their workers.

The California Public Employees' Retirement System, the giant pension fund and the nation's second-largest healthcare buyer, has already signed on as the first major customer in the Southland starting Jan. 1.

The new Vivity health plan also includes MemorialCare Health System, Good Samaritan Hospital, Huntington Memorial Hospital, Torrance Memorial Medical Center and PIH Health. In addition to their hospitals, this Anthem HMO includes all of their affiliated physicians offices, surgery centers, clinics and other outpatient facilities.

"We will have a price point similar to Kaiser or better," said Barry Arbuckle, chief executive of MemorialCare, which runs Long Beach Memorial and five other area hospitals. "This is the next major step for managed care”.

The seven hospital partners and Anthem, the state's largest for-profit health insurer and a unit of WellPoint Inc., will share in any profits and losses from this joint venture.

http://www.latimes.com/business/la-fi-anthem-hospitals-deal-20140917-story.html#page=1

Two Kaiser Permanente Executives, CIO And VP of Digital Health Jump Ship and Go For the Money at AIG

I guess you could say that CIO Philip Fasano brought Epic to Kaiser as their medical recordsimage programs was one of his projects.  He was a banker before Kaiser and worked at Capitol One and JP Morgan in IT. 

Madhu Nutakki, KP’s VP of digital health is also leaving and going to AIG.  The whole world knows who AIG is as all you have to do is think about subprime loans and the crash. 

This makes 2 key folks in the Kaiser IT business leaving.  BD 


American International Group Inc. Monday named Philip Fasano chief information officer and executive vice president. He begins in October and will report to CEO Peter D. Hancock, who took the helm earlier this month.

Mr. Fasano’s responsibilities will include guiding AIG’s Big Data strategy, powered by the property-casualty, life and retirement insurer’s vast amounts of customer data. He replaces Robert Dickie, who left the company for AIG rival Zurich Insurance Group Ltd. in February.

Mr. Fasano joins the insurance giant from Kaiser Permanente, where, as EVP and CIO since 2007, he led a number of data projects, including the $4 billion construction of Kaiser’s electronic health records system for 9 million patients. Kaiser analyzes data captured from the EHR system to improve patient outcomes and help the health-care provider monitor patient activities, such as failure to refill prescriptions.

http://blogs.wsj.com/cio/2014/09/15/aig-finds-new-cio-philip-fasano-at-kaiser-permanente/

Senin, 15 September 2014

In Texas Hospitals Having Issues Employing In-Network Doctors With United Healthcare & Humana-Found One Insurer Still Listing An In-Network “Dead Doctor”…

Sometimes the ER doctors and hospitals have different contracts and this is beginning to be an issue in Texas as it ends up with patients getting sometimes huge unexpected bills.  I had to laugh when I saw a “dead” doctor listed at I thought Healthgrades and Vitals were the kings of dead doctor listings but look like insurers leave in them in network for some amount of time.

Healthgrades Partners With Athena Health To Provide Easier Access to Book Appointments, Like Maybe Doing Better With Sorting Out Some of the “Dead doctors” Seeing Patients in the After Life?

At some point this has to change as consumers can’t continue to work with this and keep shifting and know when every tiny change is made, it’s too much anymore based on contracts that change at the drop of a a business intelligence algorithm.  That’s what’s going on.  At United we have the “secret scoring” where they are being fired and given no reason why, so you know it’s an algorithm making that decision.

“The Secret Scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..

Oh and they all cite the patients who can’t the right information, even though websites are not fully updated an so on, it’s always the patients fault.  Here in California the CMA is also up in arms with United, heck they are using as they stated a model to grade doctors that’s been in use since 2005.  I found it funny they said that as models don’t last that long and continue to work for that many years in healthcare or finance for that matter, ask a hedge fund quant.

United “Quantitated” California Doctor Premium Designation Ratings For Consumers, A Few Minor Changes-CMA Still of Opinion Ratings Cause Harm to MDs and Patients With Inaccurate Designations and Flaws…

Here’s a link from a short while back where United is shuffling patients around and firing doctors, trying to match patients up with other primary doctors but their algorithms are not doing too well as Medicare Advantage folks found themselves getting letters referring them to an OBGN and a neurosurgeon as their new family practice doctors. 

Patients In Tennessee Speak Out About United Healthcare Firing Their Doctors As the Effort Continues To Reduce Their Own In House Overhead With Managing Fewer Doctor NPI Accounts, Contracts and Billing…More Killer Algorithms At Work Hurting Seniors

Patients are not only over whelmed in Texas but all over the US and again this has to stop with optimization of networks and the AAFP recently wrote to insurers about this topic as well.  Doctors and patients are people and they can’t jump and run when algorithm comes calling.  This is exactly what’s happening and the insurers business models themselves are failing if they can’t do better data matches and bring the human elements into the picture.  This is not the patients fault as insurers and many have said this besides me, thrive on complexities as it means profit so there’s no incentive for them to really stop it either. 

AAFP Says We’re Not Going To Take It Anymore With Optimization of Provider Networks - Specifically United Healthcare’s Doctor Dumping That Disrupts Continuity of Care

Trey Berndt, an associate state director for advocacy with AARP, told lawmakers emergency-room visits present special challenges for price transparency because hospitals sometimes contract with emergency-room doctors who do not participate in the same insurance plans as the hospital. A website listing which hospitals have in-network doctors in their emergency rooms is not going to help a patient undergoing a stroke, he said.

“The transparency stuff does not work in an emergency situation. You don't have time," said Berndt, whose organization advocates for people of retirement age.

The report found that in emergency rooms at roughly half of in-network hospitals for United Healthcare and Humana, two of the state’s three largest insurers, there were no in-network physicians.

Lawmakers also considered the transparency issue outside of emergency rooms. State Sen. Leticia Van de Putte, D-San Antonio, called on insurers to regularly update their lists of in-network doctors. She cited an example of a dead doctor who was still listed on one insurer's network. She also said the state's current transparency requirements — including a rule that insurers give written notice to patients who could face higher costs from out-of-network providers — are insufficient.

Charles Bailey, representing the Texas Hospital Association, said consumers were often overwhelmed by how complicated the health care system can be, but that “hospitals are doing their best to help educate” them. He acknowledged it was a problem that hospitals are “not always able” to employ in-network physicians.

http://www.texastribune.org/2014/09/15/lawmakers-take-transparency-health-care-costs/

Humana Loses Major Contract in Wisconsin to the “Too Big To Fail Insurer, United”

Humana is much smaller in size and 75% of their entire business is Medicare Advantage and I am reading this to be a contract that is not imageMedicare Advantage in the fact that this contract covered 5,000 employees of the Business Health Group.  I might make a guess and say that price had something to do with this as just common sense Humana might not be able to compete here.  I say “too big to fail here” as that’s what’s happening with one insurer outsizing the rest in the country and having 15 pages of subsidiary companies at the SEC listed, although you might not see that today as many have been now absorbed by the Optum division, but they are still there along with the huge number of government contracts United has by comparison to the other major insurers in the US.  United makes 1/3 of their profits from software, consulting and things outside selling policies today, and that’s the other 2/3rd of the business.


In a major loss to Humana’s Wisconsin business and a possible blow to the Business Health Care Group, Northwestern Mutual has changed its employee health plan from Humana to UnitedHealthcare.

A spokeswoman for Northwestern Mutual, which has 5,000 employees locally, said Monday the change is effective with the start of the company’s open-enrollment process this fall.

“Northwestern Mutual has chosen UnitedHealthcare to administer our medical plans as we desire to continue to guide our participants to higher quality care and better outcomes at a reasonable cost,” Northwestern Mutual spokeswoman Betsy Hoylman said. “UHC provides many easy-to-use tools and resources to help our employees make informed choices based on having more background about health care providers, including information about outcomes and cost of services.”

http://www.bizjournals.com/milwaukee/news/2014/09/15/northwestern-mutual-switches-to-unitedhealthcare.html?page=all

Sabtu, 13 September 2014

United “Quantitated” California Doctor Premium Designation Ratings For Consumers, A Few Minor Changes-CMA Still of Opinion Ratings Cause Harm to MDs and Patients With Inaccurate Designations and Flaws…

This is a continuing story of the California Medical Association asking for a delay with starting the United Premium Designation Program and you can read more at the link below where they said no, algorithms have to run no matter what.  You may not even know what the Premiums Designation is but it’s more analytics and scoring of doctors that they have to go through to maintain being in network with United. 

CMA Asks United Healthcare in California To Delay Premium Designation Program With “Scoring” Doctors for A Few Months, But “No Give”, Its Starting in August, Algorithm Says…

The company says this program started in 2005 and that’s about right as I remember reading a brochure and information about it I said recently around 10 years back to my memory fits well here as at that time I was spending a lot of time around a primary practice office writing and programming an EMR which I sold for a very short time.  You see a lot of stuff when you spend a lot of time at a doctor’s office.  You can also visit the company’s site for MDs and see what all they have in store for MDs.  Doctors can log in and see their Premium Assessment Results from there.  There’s a pdf that will make your head swim as a patient that outlines all the grading formats.  Here’s all the Optum/United software that is used for this complex evaluation from claim data. 

“The Premium program uses different software programs to collect or "group" claims data into quality measures and episodes of care, including  Symmetry Episode Treatment Groups® (ETG®), Symmetry Procedure Episode Groups® (PEG®), Symmetry Episode Risk Groups® (ERGs®), Symmetry EBM Connect®  and 3MTM All Patient Refined Diagnosis Related Groups (APR DRG).”

The Practice Rewards page is left blank.  So they have tools for the doctors to use with the symmetry software and the first is what they call EMB Connect which includes all the data from claims and is supposed to help doctor assess you, the patient  to make you more compliant.  Then it goes on to episode risk groups teaching doctors more on how to do a risk assessment on you and tools to predict your current and future healthcare usage. 

There’s a couple others as well called Symmetry Episode Treatment groups and Pharmacy Risk and those dive into  Population Health risks and assessments. So did you think population was a CMS invention, nope, it’s been here for around 10 years as I remembered seeing the beginning stages and all one has to do is pretty much just read the United Healthcare Annual Report and you can see where CMS gets their models and it’s been that way with a flurry of United people in government ever since Hillary Clinton rescued Lois Quam, who was a big executive at United, who was one of many who were named in the DOJ Criminal case the SEC brought forward in 2008-9 related to back dating stock to increase the value.  I think it’s still the largest derivatives fine on record.   The former CEO took the hit and the current CEO rushed to give his money back and moved into the current CEO job from being the former COO or CIO. 

Anyway, as you can see here there’s a lot going on here with evaluating all the data on the doctors and when you add on that many of them in southern California via use of complex contracts are already getting paid at rates less than Medicare, this does not make them real happy to have a bunch of algorithmic figures and more analytics to jump through.  This process has become more complex as all health insurers are hiring more quants to create models, although United I could guess has had their share for years since that’s where 1/3 of their revenue comes from these days, analytic, software, licensing and 2/3 from selling policies.   You do have to wonder on top of their algorithms and models they are when you see the company just kick out a check for a $175,000 hammer toe procedure and then again hammer down many doctors to getting paid less than Medicare. 

$175,098.80 To Fix A Hammer Toe Billed by New York Podiatrist And the Insurer Paid It, Well Sort Of As They Sent the Check to the Patient By Accident, A New Investigation For “Out of Network” Charges Has Resulted

There’s also this example here too where the company goes out and bids and wins a Medicare Advantage contract and then has to give it back as they had no doctors in network to see the patients. 

Howard County School Board in Maryland Rescinds United Healthcare Contract As Retirees Didn’t Want the Medicare Advantage Plan, No Providers Available..

Here’s a couple more quotes on the system and see how your doctor has to be quantified by United Healthcare with stats, that may or may not lead to better care but this is the deal to be a Premium so remember that when you see the rankings.  You’ll know that United has quantified him/her with numbers and is working to put you the patient into population health management and keep your doctor in the evidence based medicine area, so if he/she varies outside of what evidence shows with something new where there’s no evidence yet, they slip down a rank or so. 

“EBM Connect helps you assess patient compliance with proven evidence-based treatment standards.  EBM Connect compares the medical claim, pharmacy claim, lab result and enrollment data from your plan with evidence-based best practices for over 90 clinical conditions and almost 600 measures of care. These measures provide a quantifiable basis for actionable interventions by health plans, employers, disease managers and others.”

So as you can see there’s a lot here and why the CMA was asking for some changes and delays and their concern on you’re the patient being confused when you see the “Premiums” rankings.  It means your doctor has been quantified and that’s a model and all models have flaws as well.  I think where the CMA is concerned as this article says is in the fact that relying on such quantification heavily will hurt the doctor and patients, and we all know how flawed data is all over the place today.  You will be steered to a layer of tiers, to select a doctor.  imageActually if you wait long enough the internet with all the flawed data out there today will end up in time giving you some kind of diagnosis:)

Data Brokers Are Now Diagnosing Consumers With Diabetes And Other Chronic Conditions–”Over Rated And Broken Predictive Behavioral Math Models” Providing a Diagnosis That Should Always Be Documented From Your Doctor, Not From The Web

So if it were me, I’d still ask others about doctors as that’s still the best and you’re going to get a “data presentation” of your intended selected doctor and not the whole picture.  There’s a video at the footer of my blog, #1, called “Context is Everything” and I advise everyone to watch it and see how you get duped on data and numbers and make choices with too much virtual world value and not enough real world value. When you ask another person about a doctor, you’re getting “real” world value and when you look at a doctor’s “data” this is all virtual stuff here with quantitated mass data using criteria that an insurance company decides is what counts, not you.  This is a real problem today with way too many confusing virtual and real world values and insurance companies are not immune to that either. 

“People Don’t Work That Way” A World of Broken Software Models That Don’t Align To the Human Side,Too Much Push At Times With Only A Proof of Concept That Fails in the Real World..

I’m sure this is part of what the CMA is trying to address here is that stats and numbers don’t tell the whole story and boy do we remember that with the VA in Phoenix as they could not get into the real world when interviewed by Anderson Cooper and he too walked away scratching his head saying the same thing, “all they could talk about were their numbers”.  Some of United’s models now are starting to fail anyway in some other areas as just like hedge funds their models fail after an amount of time and don’t make money anymore and the same with models like this, they get dated and either need an update or be dumped as they may no longer work with current economic times.   BD

VA Crisis Should Be A Huge Wake Up Call , We Have Turned Into a Nation of “Stat Rats”, Losing Touch With the “Real” World As Virtual Values Confuse, Collide and Wreak Havoc As Models & Formulas Fail


United Healthcare (UHC) has agreed, at the urging of the California Medical Association (CMA), to make some changes to its Premium Designation program. However, UHC refused to address many critical problems that CMA had identified, and CMA still believes the program continues to have serious shortcomings. CMA continues to urge UHC to make additional, more meaningful changes with its physician rating and tiering program.

"In its current form, the program will not only confuse patients but will also fail to provide them with meaningful information that could actually assist them in making important health care decisions,” wrote CMA President Richard Thorp, M.D., in an August 13, 2014, letter to the insurer.

The program uses clinical information from health care claims to evaluate physicians against various quality and cost-efficiency benchmarks. CMA believes that the program as currently planned will only lead to confusion among patients and physicians and fails to achieve a central stated goal of UHC –to modify physician practice patterns to improve both quality and cost-effectiveness.

UHC has regrettably chosen to avoid making any substantive changes to the Premium Designation program. The serious flaws that were ignored by UHC and remain in the program, CMA continues to believe, can cause real damage to physicians and patients, especially as UHC begins to use the inaccurate designations as a basis of steering patients into various tiers.

http://www.cmanet.org/news/detail/?article=united-to-make-some-changes-to-premium

Rabu, 10 September 2014

Apple Gave Us Yet One More Day of “Quantitated Madness”–More Proof of Concept Models And Software Thrusting “Virtual Values” Into a “Real World” Where “People Don’t Work That Way”…

Well yesterday came and left and I have been reading over and over that the life of most mHealth apps is around two weeks, so look at the money spent on all of this again and you come back to square one with pushing models on humans they don’t want and few have interest in.  It’s all about making money and there’s nothing wrong with that as we all need a certain amount of money to survive but what I saw yesterday was yet one more example of how “virtual” things have become. We hear over and over how all of the devices are going to make things better but instead we have a world of consumers just “pounded” with marketing as companies have spent a lot of money and when they find out “people don’t work that way” here comes the marketing to “force people to work that way” and I saw a lot of that yesterday.  Apple is not alone, it’s all around you and when people don’t buy, out comes the marketing, fake studies and skewed numbers to “make you believe” that everything out there will make your life better.

The truth is not always such.  As a matter of fact there’s a lot of irritation to most of this as we see our “Algo Duped” Congress who can’t do little anymore as things have gone over most of their heads and some are zoned out into the same “virtual” values that do little for the real world.   This is very difficult indeed for doctors as they have to deal with the “real” world every day, patients, and they too have to balance the somewhat nutty technology we see and find what makes sense. 

So now that companies have all spent these ghastly amounts of money on some broken models, what’s left?  We can look forward to more data selling, more expense with non relevant data being used and of course we pay for all of this as well.   Because of all the money spent creating queries and software though, it’s going to be forced upon us to go against the grain of the “real” world and buy in to all of this and we will continue to see one failure after another as our society gets angrier as with time and more failed models, the Algo Duping becomes more apparent.  I’m not saying it’s all bad by any means and there’s some really neat stuff going on as well but so much of it gets back burnered anymore as the “junk” hops out in front.  I used to write software and thus I have some real admirations for talented people who do create great solutions too, but again that’s not what makes top line news today. 

“People Don’t Work That Way” A World of Broken Software Models That Don’t Align To the Human Side,Too Much Push At Times With Only A Proof of Concept That Fails in the Real World..

The larger iPhone I see as a real world type solution of course as who doesn’t want more screen real estate?  Everyone wants that so there was one answer from Apple that maintained a response to the “real world” desires.  A new operating system as well was introduced and that’s just part of business today and the ability for more developers to write more apps, well we get both with that option as well, more good stuff and more nonsense.  I do miss the days when big corporations maintained the “nonsense” in house and we didn’t have to hear about it until there was a pretty good chance of a a decent, usable product or service coming out.  Today we have to listen to every tiny bit of nonsense software, many of which right from the start are a “proof of concept” that’s going to fail or is written to be a “duper” to collect more consumer data to sell.

In essence, yesterday Apple just became a bit more virtual with the “watch” and the idea that we are just climbing the walls for mHealth apps.  Sure they have spent a lot of money as have many others and there are good professional mHealth apps that doctors use, many FDA approved as well, but we get the quantitated “junk” mostly and I didn’t see yesterday as being anything different.  If you are thinking the mHealth devices and apps are ready for EMR integration, well think again because that too is a long lengthy and costly road.  Wake up to the reality here. 

Of course anyone in the Health IT business knows that if anyone can or wants to do anything, it’s Dr. Halamka at Harvard Medical and I just head his post and guess what, that’s exactly where we go with all of this.  Of course we all rely on his viewpoints and expertise and yesterday was no different as he wrote he spent time using the technology…

“Apple created an enormous white pavilion next to the Flint Center for the demonstration of these products.  I spent the afternoon using the technology they announced.

Recently, a donor committed significant funds to the development on an app that will do just that.    We hope to have a running prototype in 2015.”

We don’t know who the donor is but read his comments and someone’s paying a lot of money for an app to be developed that “could” work with EMRS.  As I always say, “the short order computer code kitchen burned down years ago and there was no fire sale”. 

Dr. Halamka seems to agree with exactly what I have been saying for a long time too, the answer is “middleware” and this is the case here too. Keep in mind he’s also looking at a lot of this for the first time and you know what’s going on as far as structure until you dig in to the code here.

So anyway, you can dream on for a while and I hope we get something worthwhile from Harvard as Dr. Halamka is always hands on and not marketing more “quantitated madness” for what he says and does, unlike the rest of what you see out there.  We are already seeing a great deal of non relevant software and analytics just being pushed in our faces constantly and the “dream of the sexy job” of being a data scientist.  One some of that you can almost laugh on if you understand some of their math and the number dupes that occur.  Scroll down and watch video #1 in my footer if you want more on that and how we all get duped over and over and over again with numbers.  That’s not going to stop any time soon either as “duping” is very profitable until the model just falls on it’s face and won’t work anymore with the arrays of data, subprime anyone? 

How Long Before the Data Scientist Demand Begins To Slow? About Half of the Analytics Investments Will Be A Wasted Investment As Some Data Will Prove To Be Non-Relevant to Solving “Real World” Situations At Hand

Dr. Halamka also stated it has become a war with security and his job as a CIO of course is going focus more on that as a priority while the the little watch project will fall in somewhere down the line.  We need security with medical records, the little watch is an option that’s going to cost money as well so it has to take it’s place of being a virtual value as we work in the “real world”.  

It’s Become A War To Keep Patient Medical Records Secure And Out of the Hands of Hackers, Data Selling Epidemic in the US Fuels This Fire…

Ok so now that the virtual nonsense of the watch and Apple Pay is done we can get back to the real world today and go about our business and hopefully we may have learned one more thing from yesterday, be a skeptic when you need to be.  Here’s a great essay written by a quant on that topic who does models and has for years.  We are living in “Duper Ville” at times and the key is to figure out what’s a real world value and what’s virtual and ask “am I being duped” again. 

I’m not specifically attacking Apple by the way at all but rather just addressing their contributions to the world of some additional confusion for consumers in graying out virtual versus real world values and we had a bunch of that yesterday, it’s a real problem today as even our White House puts out emails with “junk science” numbers posted that nobody can predict, so there’s a ton folks in government that are duped as well, and that’s really the scary part as they become more virtual being duped and corporations and banks run more of the country. 

“On Being a Data Skeptic- Modelers Have A Bigger Responsibility Now Than Ever Before”–A Must Read Essay, Start “Sniffing the Data”…

The credit card people too were excited too yesterday as more you use that credit card, the more data they get to sell and I wrote about that last year as a warning as Master Card was bragging about what they are doing today and how profitable their data selling ecommerce was going to be, yup, selling our transaction data. 

MasterCard Recruiting Software Engineers For New e-Commerce Technology Lab, Maybe More Slicing and Dicing of Our Data To Sell to Insurance Companies for One? Be Wary of Corporate “Algo Dupers” Out There Feeding on “Nonskeptical Consumers”…

If you want to know more about how this works, visit the Killer Algorithms page where people smarter than me explain some of this for you as it’s not going away anytime soon as long as folks in the virtual worlds can come out and harvest some real world values and make billions.  BD

Attack of the Killer Algorithms – “Algo Duping 101″

Selasa, 09 September 2014

Optum Labs Add Four Additional Data Miners To the Collaboration Looking for Data…

If you are not familiar with what Optum Labs is, it functions in Massachusetts where hospitals system like Mayo, McLaren, Dignity and I think a couple more de-identify and send all their medical records system to their labs to where the data is cleaned, formatted, etc. imagefor paying data mining members to use for research, painstakingly looking for information about their drugs or products, in the case of Merck and Boston Scientific or other entities wanting to research for particular conditions, diseases, etc.  When the labs first opened they explained there were two kinds of memberships and the hospitals, such as Mayo are “owners” which means they have an opportunity here to maybe make some money along the way. 

Boston Scientific Joins Optum (United Healthcare) Labs - Research for the Good With Profits Built In For Those Providing Medical Records And Data…

Four new members were added today and these all look like the paying miners from what I am reading, again looking to find something, anything to query to see if they can find some value in the data.  The University of Maryland stated they are looking for information relative to Alzheimer's and healthy aging.  Optum Labs provides the apps for the data mining on their system.  Merck is another new member and of course they are looking for drug information relative t their products. 

UnitedHealthGroup and AARP Get Cozier, AARP Still Gets Paid for Marketing Use of AARP Name As AARP Becomes an Optum Labs Data Selling Promoter Amidst Doctor Complaints Received Relative To United Firing of 5500 MDs–Subsidiary Watch

These are just long tedious data digs and Harvard Medical School HealthCare Policy group is another new member and their focus is education so not exactly sure what they might be digging for other than maybe information for studies as a guess as well as Media Research, another new mining member which is located in Minnesota.

United Healthcare Adds McLaren Care Health System Into the Shared Clarity Data Mining And Selling Venture Along With Dignity Health

They also have Humedica that they paid hundred of millions of dollars for that can kick in here too with selling de-identified patient medical record data.  Humedica will be able to package up the non identified data and sell it to pharmaceutical, device  companies and others. Humedicauses a portal service for the hospital analytics and the information sold from EMR records can show which products are doing better, worse, etc.

This sounds like it’s direct competition for the FDA Sentinel program too as remember back a few years ago when insurers were going to donate claim information to add to the device and drug files that were being gathered to evaluate for safety along with medical records added.  BD

Senin, 08 September 2014

It’s Become A War To Keep Patient Medical Records Secure And Out of the Hands of Hackers, Data Selling Epidemic in the US Fuels This Fire…

We all should know or be aware of the fact that the US has a data addiction and selling problem.  We don’t do as much manufacturing anymore as any company out there with data knows there’s cash burning a hold in the company pocket if they can sell it.  We end up with data being sold to where the end buyer finds out later that what they bought and are trying to use puts no real money to their bottom profit line.  That’s a slow process indeed as people keep hiring data scientists thinking there’s a profit rabbit on every corner to pull out of the hat, which is not true.   imageThese are more of the data novices that really get caught up in all of this as someone selling software can really hype you up on the fact that you need it and thus with that type goes the hacker hype and interest too.

How Long Before the Data Scientist Demand Begins To Slow? About Half of the Analytics Investments Will Be A Wasted Investment As Some Data Will Prove To Be Non-Relevant to Solving “Real World” Situations At Hand

So now we are seeing some of the biggest hospital systems being hacked and how far they get access varies.  Instead of a major focus on security, healthcare prefers to sit around and create data and images to view and say “look how pretty my infographic is”…like on obesity which is very visible and I see it every day but for some reason folks think this needs to be mapped over and over and over

The breach at UPMC was pretty bad too and the hospital records of employees were accessed with fake income tax returns filed and bank accounts drained so other than medical records there’s other hacker cash cows they can go after. 

UPMC Medical Center Workers Protesting Low Wages While Investigation of Employee Data Breach Continues With Fake Tax Returns and Bank Accounts Drained..Double Whammy

Instead of all the little silly start up stuff, why doesn’t Silicon Valley put more effort in to this area if they want to be constructive instead of masses of “me too” types of software that end up in the “glut” pools with millions down the drain.  We don’t know who the real data sellers are in the US either so it’s easy enough to confused hackers with real data sellers that are making billions selling our personal data sometimes as Experian found out with not doing enough due diligence on a company they acquired and is still the largest data breach exposure around, 200,000 million US citizens, about two thirds of the US population.   Experian bought a company that had a hacker already built in that the Secret Service found later.  Read the link below for the full story on that breach.  BD 

One Really Good reason to License and Excise Data Sellers, Huge Breach As the “Data Selling Epidemic” Both Legally and Illegally Continues To Grow-All We Have Are Lawyers Who Only Do Verbiage While “Code Runs Hog Ass Wild” -Due Diligence is Dead


Demand for health records is high. The FBI estimates one goes for $50 on the black market, much more than the few dollars often required for credit card numbers. Ponemon Institute, a research center that examines data protections, says breaches cost the industry up to $5.6 billion a year.

Stolen health care data can lead not only to financial loss but also to inaccurate medical records and, thus, misdiagnosis.

These and other recent incidents reveal the growing market for patient data and perilous gaps within the health care industry.

“It’s a war we’re in,” said John Halamka, the chief information officer of Boston-based Beth Israel Deaconess Medical Center and cochair of the Health IT Standards Committee, a federal group that advises the government. “Hackers innovate and find new ways to get in and those who store data innovate and find new ways to keep them out. We’re leapfrogging back and forth.”

Halamka considered this summer’s attack on the hospital operator, Community Health Systems, one of the most sophisticated he’s seen and an example of the increasingly clever methods of cyber criminals.

http://www.bostonglobe.com/news/nation/2014/09/05/health-care-industry-ill-prepared-for-vicious-cyberthreats/ZdvDGaipJi7VSN0TogezkL/story.html

Stanford Hospital Ends Contract With Anthem Blue Cross, About 10,000 Patients No Longer Covered There

This went into effect at midnight as the two could not come to an agreement.  As I read this, a two year agreement was reached but not the three years that Stanford wanted.  This was not the first time this happened as it’s a repeat of 2011, same thing.   imageTime will tell how long it takes this time before the two come to terms.  Stanford Medical is also in the process of trying to save a small hospital system from going out of business and is talking to acquire them.  Nobody likes to talk about “hospital inequality” to include CMS but it’s there slapping you in the face every day.  Anyway if patients continue to go there they will be considered out of network now if they have Blue Cross Anthem insurance and it will cost more.  They say Stanford is one of the most expensive hospitals in the state but heck they need the money to bail out these other hospitals right now, right? 

Stanford Hospital In Talks to Throw Valley Care Health System A Life Line to Merge

There’s no doubt that Stanford is a top notch hospital in a lot of what they do there for sure.  The annual MedX conference just ended there yesterday afternoon with e-patients and many more and this was the climax to all of it with this.   As I understood both sides were working to come to some kind of an agreement yesterday but obviously it didn’t work.  BD


STANFORD (KCBS)— Some 10,000 Anthem Blue Cross members are no longer covered at Stanford Health Care because of a contract dispute where the hospital abruptly cancelled Anthem’s contract.

Anthem’s president sent a letter to Stanford, calling on the hospital to rescind its termination so that members could have uninterrupted care. The two sides have been negotiating a new three-year-contract.

A Stanford health-care spokesman told the San Francisco Business Times that they want an agreement for a third year on the exact same terms as the first two, but said Anthem is not agreeing to it.

http://sanfrancisco.cbslocal.com/2014/09/08/stanford-hospital-cancels-anthem-blue-cross-contract-after-dispute-thousands-without-coverage/

Minggu, 07 September 2014

Tenet Physician Group Discussions Taking Place Now in the OC Relative to a Potential National Physician Contract–Company Taking Bids From 3 Major MD Staffing Companies

This discussion has been moving from one area of California to another and the OC represents a substantial group of doctors in the current groups.  In the discussions it’s still not clear yet if this is an all in or selective process yet.  Many of the doctors in their groups have been under contract imagewith Tenet for a long time and the obvious would be to keep those doctors for less disruption in care.  What the pay cuts maybe for those doctors is not yet known.

The ER Department is a big part of this discussion as the 3 companies want the profitable ER business and will absorb losses with staffing hospitalists if need be according to this article.  Of course this is all at this point still up in the air and the main incentive driving this is for Tenet to save money, what else.  Tenet is headquartered in Texas to where they are both building new hospitals and acquiring a few others.  In the Palm Springs Desert area a couple months ago, contracts with surgeons have already taken place. 

Tenet Cancels Contracts With Orthopedic Surgeons in Palm Springs While Unrest Still Continues in California As the Company Mulls Over a National Contract for Doctors - Healthcare Still Supporting the Stock Market

The announcement of contracting for a nationwide contract for physician staffing originally was discussed in the the coastal areas just north of Los Angeles and those folks too have their concerns.  We have been reading that some of the traffic now that would normally be taken care of in the ER rooms now has patients visiting free standing surgical or free standing urgent care facilities.  In Texas hospitals recently stated they are starting to see this impact with a the number of patients visiting the ER decreasing.   Now Tenet also has their own network of Urgent Care Centers they just rebranded, “MedPost” which have several locations across the US.  One might also question if a nationwide contract would also cover physicians working at these centers too.  What is also interesting is that you have insurer, United Health under their subsidiary name of Optum out building their own urgent care centers, 2 have opened in Texas and would stand to perhaps compete with Tenet in this area, although the two companies just signed a new contract nationwide not too long ago. 

Tenet Hospitals Announces Rebranding Urgent Care Services Now “MedPost” -Emergency Room Visits Keep Rising

In addition, not too long ago Tenet bought Vanguard Health for $1.8 billion in cash so there’s some expenditures going out in that direction as well. 

This will be interesting to see how this works out with everything that is happening in healthcare right now.  If in fact there’s more business leaving the ERs and moving to freestanding centers then the 3 companies bidding on the national contract if one of them secures a national agreement to further cut losses from the hospitalist side and even perhaps cut physician wages even more, and of course that’s the huge fear of all the doctors, plus they have to meet the standards, which we don’t know what they are exactly, of any one of the 3 companies who could win a nationwide bid. The profit margins are very slim for such nationwide contracts as well. 

To support the corporate structure of one of the potential bidders there’s going to have to be money taken from the various ERs to support that over head of the staffing company too so those Tenet hospitals could see lower staffing and doctors required to see more patients per hour as well which means a decrease in the quality of care overall.  BD 


National hospital chain Tenet Healthcare is considering replacing local independent doctor groups with a large national physician staffing company at some or all of its 12 California facilities.

Doctors in Orange County and across the state fret that bringing in an entirely new group from out of state to manage three different sets of physicians could disrupt established relationships between them and their hospitals and usher in a new era of penny pinching that would reduce staff levels and doctors’ pay.

Earlier this year, Tenet notified medical staff at its California hospitals that it was thinking about terminating current contracts with emergency room, anesthesiologist and hospital specialty doctor groups in order to bring in a single company that could provide physicians for all of those functions. It has solicited and received bids for the proposal.

The California Medical Association, physician associations and the medical staff leaders at some of the Tenet hospitals have weighed in against the plan.

“It’s like saying to Coke, ‘We are going to change you to Pepsi. Everybody will stay; they just care about cola,’” Futernick mused. “But I think many physicians will leave, especially if they are part of a group that is bigger and has other contracts. I think some of the physicians will stay, but at greatly reduced pay rate – especially if they have fewer options.”

There is some confusion over the scope of Tenet’s plan. Doctors working in Tenet hospitals said they believed the staffing change would be at all of the company’s California hospitals. A spokesman for Tenet, however, said, “some of the hospitals may choose to remain with their current physician groups.”

Nonetheless, Tenet has at least three large physician staffing companies bidding for the business and ready to jump in: EmCare, a Dallas-based company with $3.7 billion in revenues; Team Health, a $2.4 billon Knoxville, Tenn., company; and Apollo MD, a privately held firm headquartered in Atlanta.

http://www.ocregister.com/articles/tenet-633989-hospitals-doctors.html?page=1

Sabtu, 30 Agustus 2014

Feds Decide to Intervene, File Their Own Lawsuit Against Optum (United Healthcare) Hospice Services Relative to Whistleblower Fraud Cases Already Submitted- Pay for Performance Issues With Hospice Performance and Medicare Fraud At the Core

Optum Hospice used to be known as Evercare until the last year when United Healthcare subsidiary, Optum rebranded the company.  To me a hospice company owned by a health insurance company just doesn’t mix, especially when the same corporation has truckloads of subsidiary companies that are not always apparent to the consumer.  2/3 of United’s profits come from selling policies and the other 1/3 comes from writing code, selling software, consulting and so on, in other words Health IT.  Optum also wants to be contracted integrators as well for major medical record systems as they list on their website.

I read a little bit of the case and the accusations are amazing as it comes right back to almost slap the insurer in the face with the allegations of pay for performance measures as it is stated they created an incentive to staff to admit and retain ineligible patients by giving out bonuses and other incentives based up on meeting their targets.  It’s also beginning to sound like the same stat rats at the VA as well, who were so stuck on numbers they could not make a left turn to save a life.  The bonuses (or as sometimes called P4P) were for staff members who admitted, certified and recertified and discharging patients. 

Employees were told there would be staff reductions or terminations if the census fell below targets, as well as people could be fired or demoted for discharging ineligible patients.  Here comes the algorithms as Optum is accused of creating discharge procedures that made it difficult or substantially delayed the discharge of ineligible patients.  Let me guess, it’s all software with input and the algos give you the decision perhaps.

The lawsuit also states that contracted physicians were also pressured to improperly certify and recertify ineligible patients.  Here’s all the chronic conditions that were targeted, dementia, Alzheimer's, and pulmonary irregularities and the goal was slated that they could in fact keep patients with such conditions for more than six months.   As a result of such actions, Optum is accused of submitting false claims to Medicare and was overbilled.  This gets kind of interesting as the new #2 person at CMS that Burwell appointed, Andy Slavitt  comes from United Healthcare and was the CEO of Ingenix at the time of the AMA lawsuit (Killer Algorithms chapter 19)  that used algorithmic automated processes to under pay doctors for 15 years.  Ingenix algorithms just raised their ugly face again  within the last week with a Blue Cross Company still using them after most everyone else settled in New Jersey.

Ingenix (Optum-United Healthcare) Lawsuits Still Bouncing Around Out There–One Recently Settled in New Jersey With Horizon Blue Cross Blue Shield That Was Still Using the Flawed and Corrupt Data Base for Out of Network Payment Calculations

Optum Hospice is on the move too and growing with opening new facilities.

Optum/United Healthcare Opening New Hospice Care Facilities In Birmingham & Macon, Hospice For Profit-Evercare Subsidiary to Gets Rebranded To Optum Palliative and Hospice Care

It goes on further here with employees being given a “scorecard” for each Evercare Office and the offices that were meeting goal would receive positive points if the average daily census met goals.  This sounds like the ad business here with those offices who converted 85% or better of their referral getting a bonus.  Also the case says that offices were penalized if the discharges of ineligible patients exceeded 10% of the average daily census.  Bonuses could be as high as 20% of their annual salary.  This goes on to talk about a sales force hired called Communityimage Outreach who’s duty was to troll nursing homes, hospitals and other care facilities to obtain new clients.  Now sales portions take place everywhere and nothing wrong with sales people, and they received commissions on the news of new admissions.  I can’t see a problem there but as long as the sales calls were good will calls and not looking for ineligible patients. 

I have seen one thing on their website is that Optum, formerly Evercare is always advertising for people to come volunteer and work for them.  Both the contracted doctors and employees told Evercare they had ineligible patients that needed to be discharged and decisions from higher up mad the decisions. 

I know when I had to chose a hospice service for my mother last year, Evercare was not on my list as I just pictured being loaded down with quantitated numbers about my mother while I was trying to see to her care in her last few days.  I report enough on United and their subsidiaries to see all their stats and how they live by them with lacking ethics sometimes and I knew better. 

It goes on here further to say that salaried physicians who worked there were also coerced and the nature of the contracts provided incentives to the physicians to keep the patients in.  In another area of United Healthcare relative to Medicare Advantage, doctors are being scored and fired across the country and are given no reason or in some cases no communication beyond a letter saying your services are no longer needed

“The Secret Scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..

The case further goes on to state that the sales force also knew that targeting the certain types of chronic patients allowed for them to be certified “terminally ill” once they were in house, which allowed them to keep them longer and bill more.  Again we go back to Phoenix, the site of the VA issues where the billing office is for Optum (Evercare).  There are several examples in the court case you can read here.  After I read through it I can see why the Feds stepped in as they are owed money according to the case filing.  United bought Evercare in 2001 so all this took place while under their ownership of the company.

The suit also states that another division of Optum, Ovations, a health and wellness company for people 50 years an over in age, worked hand in hand with Optum Hospice.  United owns a few wellness subsidiaries.  Americhoice was also mentioned which has since been absorbed into Untied Healthcare and no longer maintains the separate identity and is called the UnitedHeatlhcare Community Plan. 

So again all we hear from United Healthcare day in and day out is pay for performance so will it come back to bite in their hospice operations?  There’s some pharmacists too out there with Walgreens that get to collect pay for performance from United/Optum in some parts of the country. Are the P4P models beginning to fail?  Could be.   BD

UnitedHealth, YMCA Expand Diabetes Prevention Program with P4P for Walgreens
UnitedHealthCare To Use Data Mining Algorithms On Claim Data To Look For Those At “Risk” of Developing Diabetes – Walgreens and the YMCA Benefit With Pay for Performance Dollars to Promote and Supply The Tools

We know how United/Optum knows how to model and code with the contracts they have received for fixing not only the US exchange but also some state exchanges as well, so again watch these folks with their algorithms as they know how to hide and do it better than anyone else out there, and it’s all proprietary and it usually takes audit functions years to catch up with them.  Watch video #2 in the footer here to see how quants work and insurers are hiring them by the groves for their profit making math models.  BD 

Health Insurer Actuary Jobs Becoming More Difficult In the Era of Killer Algorithms, Can’t Function Like They Used To As Information Changes Take Place Daily And Hourly, More Insurance Companies Are Seeking quants to Create New Math Models, The Next Level Up From Actuary Calculations


Federal officials have intervened against defendants in two whistleblower lawsuits in federal court in Colorado alleging Evercare Hospice and Palliative Care (Evercare) submitted false claims for the Medicare hospice benefit.

Evercare is now known as Optum Palliative and Hospice Care, which provides hospice services across the United States.

One of the suits names Evercare’s parent companies, including UnitedHealth Group.

The complaints include allegations that management pressured employees and physicians to admit and retain patients who were not terminally ill and challenged or disregarded physicians’ decisions that patients should be discharged.

According to the lawsuit, the companies “targeted for admission ineligible elderly patients with conditions like debility, dementia, Alzheimer’s and cardiac or pulmonary irregularities that while serious were not likely to lead to the death of the patient within six months, thus allowing the defendants to keep these types of patients on their hospice census for more than six months, if not several years.”

http://www.corporatecrimereporter.com/news/200/feds-intervene-false-claims-case-unitedhealth-group/

Cleveland, Texas Hospital Abruptly Closes–Note On Door Says We Hope to Re-Open Soon, Meanwhile Back at the Ranch CMS Is Working Hard to Create A Ridiculous 5 Star Rating System for Hospitals…

One older article seemed to reflect something about a “boiler room” remodel but those are usually scheduledimage and maybe something unexpected popped up in that area as the note does reference the hospital wants to be a “safe” facility.  In addition the hospital has also had financial issues in struggling to pay both employees and vendors in the last 3-4 years.  Who knows, maybe they need a loan to fix the boiler?  RKM Management is the owner of the hospital.  The ER room is closed and the next closest facility is 24 miles away which concerns residents.

Back in 2013 the former CEO has some issues too and was on the loose for a while with assault charges against him with a confrontation with the chief nursing officer.  There’s been quite a bit of history written about this hospital struggling to stay in business.  Nobody wants to talk about this but we have a big case of “hospital inequality” in the US. 

“Hospital inequality” - Yet One More Growing Issue With Healthcare In the US..

We keep seeing more and more stories like this but in the meantime we have good old CMS with a response and answer for all of this “a new 5-star hospital rating system” and don’t you have to about fall off your chair reading this in today’s economic times?  They haven’t caught on yet that we really don’t need this today and ratings are so “yesterday” as now we want to know what facilities “will be available and open” when we need them. 

CMS Plans To Begin Five Star Hospital Rating System - Add A Column For “Hospital Mortality Projections” Or Stop the Ratings All Together As Lack of Money Today Is More of a Determining Factor With US Hospital inequality That Keeps Growing..

video platformvideo managementvideo solutionsvideo player

CMS like many others are busy living in the quantitated world of virtual numbers and sure there is valuable information when done right but they don’t know when to stop and succumb to every little bit of data having value on care, whether it does or does not.  There’s plenty of Health IT vendors out there as well to sell you any kind of analytics you want too, so again you have to be smart about it today.  The boneheads at this hospital at the link below are really addicted to the virtual worlds and don’t know when to stop as all the patient credit card and Acxiom data is not going to give better care and they got soaked as it’s not relative to giving immediate good care.  I do have to laugh at how “Algo Duped” the hospital is here.  There’s Quants working everywhere and like Felix Salmon said, a sharp journalist in this area “quants don’t know when to stop and mess up every industry they infiltrate”. 

Oh crap, Now Hospitals Are Now Buying Data From Acxiom - Data Selling Epidemic Continues to Evade on Personal Privacy As “Algo Duped-Stat Rat” People Try to Implement Virtual Models That Won’t Work…

No amount of credit card data or Acxiom data is going to help this hospital in Texas here and there’s budget for the nonsense either as they are just trying to stay in business.  CMS is kind of in a tizzy right now as many of their quantitated methodologies are starting to fail them and they don’t have a back up for the models used that were pretty much in line with what one big insurer has guided them to use for the last number of years, and they too have failing models.  We are seeing evidence of such with secretive scoring of doctors being turned loose from being network and given no explanation as to why.   BD

“People Don’t Work That Way” A World of Broken Software Models That Don’t Align To the Human Side,Too Much Push At Times With Only A Proof of Concept That Fails in the Real World..

Cleveland residents are upset and worried after learning their local hospital has shut its doors.

On Thursday night, signs were posted on the front doors of Cleveland Regional Medical Center stating the facility is closed until further notice.

"Just got sent up here for a routine chest X-ray from my local doctor, and I can't get in through the doors they are closed as of Aug. 28 and I wasn't aware of that," said resident Fulton Thompson.

Posted signs also suggested patients drive to the closest emergency room in Kingwood, which is over 24 miles away.

In an emergency, the longer distance could mean the difference between life and death.

http://www.click2houston.com/news/cleveland-regional-medical-center-closed-until-further-notice/27791330

CMS Overload of Short Term Inpatient Hospital Stays Appeals Process Leads To the Agency Offering New Settlement Proposals

This could be good and get a large number of appeals, which are slated to be around 800,000 out of the way, that is if the hospitals agree to the proposed numbers of around 2/3rds of the dollar amounts.  It could be small amounts for some hospitals and very large amounts for others.  CMS is basically offering to pay a flat amount and be done with it.  These are some of the appeals that were a result of audits conducted by contractors at hospitals all over the US in their pursuit of looking for fraud.  Stuff like this goes on forever when numbers and cases are reconstructed years after the fact.  Many of the RAC auditors are actually subsidiaries of insurance companies as well that provide such audits.  It does make you wonder how good the auditing is when in fact you see insurers with their own internal problems such as this one that emerged in New York earlier this year to where over $170,000 was paid for a hammer toe procedure.  It just makes you ask about how accurate at these auditing algorithms if you will.

$175,098.80 To Fix A Hammer Toe Billed by New York Podiatrist And the Insurer Paid It, Well Sort Of As They Sent the Check to the Patient By Accident, A New Investigation For “Out of Network” Charges Has Resulted

This is interesting as it was “quietly” posted as the New York Times mentions here.  Again it will be up to the hospitals to decide if the settlement works for them and in so many of these appeals, the hospitals have been winning anyway so it’s a matter of if 2/3rds is enough to wipe it out or are the hospitals going to hang in for the full amounts.  I said a while back that most of the auditing functions with RAC auditors are not really necessary any longer as CMS is now using fraud detecting software that catches a lot of the known patterns up front and in actuality does send auditors where they should be looking rather than just a random audit of billing practices.   Of course the RAC auditors don’t want to lose their jobs either and thus there’s the tug and pull and if it is subsidiary of an insurance company, there’s a lot of a revenue stream with the audits. 

Here’s Some Folks That Can Be replaced With Technology-Medicare Recovery Audit Contractors - CMS Yarcdata Urika Appliance Can Do This Job And Is With Finding Fraud Patterns…

“The YarcData unit is helping the U.S. government detect fraud patterns in Medicare and Medicaid payments. Private sector customers include medical research group Mayo Clinic and several financial services, life sciences and telecommunications firms, which Cray cannot name for contractual reasons.”

Due to today’s complexities and the old audit methodologies no longer containing high levels of accuracy, we are kind of spinning our wheels here with kind of a “he said she said” scenario that wastes everyone’s time. 

A good example of trying to rebuilt an audit situation was the VA and I called “foul” on this one myself as quantitating numbers is not going to change the fact that patients died but when you look at what’s put out there today, there’s a lot of this going on and you can get sucked in easy enough, we all do at times.  People are using quantitated math functionality to change virtual values that impact “what really happens in the real world”, which is very dangerous indeed, and the balance is very skewed at times when there’s money involved. 

VA Inspector General Takes the “Virtual Low Road” With Report at Phoenix Hospital, Working Some Quantitated Mathematical Justifications But We All Know In the “Real” World People Died…
Medicare Penalties for Hospitals To Take Effect Later This Year With Patient Safety - Can We Learn From the VA On Not Being “Stat Rats” And Attain The “Desired virtual Numbers” In The “Real World”?

So again hospitals, depending on their number of appeals and dollar amounts will have to make their own decisions and I would imagine there could be quite a few takers on this as it represents one less headache of bean counters in the virtual/real world confusion we  live in today which I call “The Grays”, a very big problem indeed.   

Virtual Worlds, Real World We Have A Problem And It’s A Big One With A Lot of Gray Areas Finding Where The Defining Lines Exist, Confusing Many With A Lot of Weird Values And Strange Perceptions…

100 Bottles of Beer, watch this short video and it pretty much explains what’s going on here with how some of this works and the fact that variables with reconstructing after the fact can leave to false perceptions when trying to go to the extremes with math. 

If you liked this video clip, the scroll down and watch the full presentation in the footer, video #2 of the 4 essentials below.  BD 


Sharply criticized by Congress and others, Medicare quietly announced on Friday that it would settle hundreds of thousands of hospital appeals over bills for short-term care, by offering deals that could add up to several hundred million dollars.

The decision is an effort by the government agency to end a protracted battle with thousands of hospitals over the amount they should receive for treating patients who stay just a day or two. So many hospitals have filed appeals with Medicare that a backlog now stretches for 18 months or more before the disputes are being resolved.

The proposed settlement, which was quietly posted on the agency’s website late Friday afternoon before the holiday weekend, represents a considerable concession by Medicare. The financial payout that it is offering to individual hospitals would be a little more than two-thirds of the amounts they have insisted they are owed.

Medicare “is offering an administrative agreement to eligible hospitals willing to resolve their pending appeals in exchange for timely partial payment,” said Aaron Albright, a Medicare spokesman. Mr. Albright described the offer as an opportunity for the hospitals “to alleviate the administrative burden of current appeals on both the hospital and Medicare system.”

Medicare and its contractors say many hospitals have overbilled the government for treating patients who underwent simple operations or were in the emergency room for a lengthy evaluation. They say that under Medicare rules, a hospital should receive a lower outpatient rate for that type of care rather than the much higher reimbursement for a full hospital stay, a difference that can add up to thousands of dollars for each patient.

http://www.nytimes.com/2014/08/30/business/medicare-will-settle-appeals-of-short-term-care-bills.html?smid=tw-nytimeshealth&seid=auto&_r=0

Selasa, 26 Agustus 2014

Patient in California Finds Out the Hard Way That His Doctor No Longer Honors Blue Shield Insurance Bought Through Covered California–More Consumer Targeted Killer Algorithm At Work…

I remember Regal before their affiliation with the Heritage Providers and it was no problem in the earlier days but their affiliation now is changing things for patients.  Since the patient purchased his policy through Covered California, it was ok, then one day, he can’t see his doctor anymore as they don’t see any Covered California patients.  That is frustrating and this might go back to the mess with doctors getting paid 30% less from Blue Cross and Blue Shield with policies bought through the exchange.  It was so bad for a while that the insurers had to go back and up the reimbursement a bit and still the lists of who was in network and who was not was still a mess. 

In some cases the insurers were sending the doctor reimbursements to the patients who wanted to keep the money. 

Blue Shield Billing Fiasco With Policies Bought Via Covered California - Checks Are Going To the Patients and Not the Doctors Who Some How Ended Up No Longer As Covered Providers…More Killer Algorithms Creating More Obstacles to Getting Care…

Here’s what one doctor has to say:

“Blue Shield announced to all that for their Covered California Health Plan all its Blue Shield providers are on the plan. I had patients sign up specifically because they saw I was on the plan (the same happened to other physicians as well). However once the plan went into effect most of the physicians contracted with Blue Shield were no longer listed as contracted providers.

Furthermore after we provided services to  these patients the Explanation of Medical Benefits fromimage Blue Shield showed that we were discounted some 20-30% of our previously paid services and the check was now going to the patient and not the provider.   We have been trying to get these checks from the patients who love getting these Blue Shield checks and keeping them. As physicians are finding this out they are mad and are starting to demand payment up front from the patient and give them a superbill so they can bill Blue Shield. What a mess.”

So maybe Regal decided not to mess with it at all?  What really made the patient mad is the fact that Heritage gets grants from the Feds for being an Accountable Care Organization and is so well touted as being a model, and yet there’s no model here and no care for him and he especially was not happy about the mention of Medicare patients getting free dance lessons and healthy cooking classes as well as casino excursions when he couldn’t see his doctor. 

So here we go, everything working fine and then all stops due to a bunch of crappy algorithms that won’t work together.  This is what the big problem is with Obamacare, everyone’s math that doesn’t jive.  BD 

Obamacare - One Big “Attack of the Killer Algorithms” No Matter Which Direction You Turn, Compounded With a Lot of Government and Consumer “Algo Duping”….


We've had the same doctor for 20 years. On August 1st his individual practice merged into Regal Medical Group, a large, multi-area medical group. Regal Medical Group is an Independent Practice (or Physician) Association, or a group of individual doctors who combine their practices into one large group.

No problem, we thought. Sure, they're located farther away, but it's not terrible. Worth the extra time driving to keep a doctor who knows us and knows our history. But we just discovered how wrong we were.

I've written in the past about our son's ongoing health issues. Last year, he signed up for Covered California and bought the Platinum plan through Blue Shield. It's expensive for a 25-year old, but he wisely decided it was worth paying extra for the peace of mind he would get from knowing he'd have deductible-free coverage for his health issues. His doctor was in the network, so all was good.

Until the merger. This week, he had a flareup on the diabetes management side of things and so he called the doctor and made a sort-of-emergency appointment. He showed up for the appointment this morning, presented his insurance card and was told they don't take any insurance under Covered California.

I couldn't quite believe the text I saw from him. Blue Shield policies are exactly the same from a coverage and deductible standpoint, whether purchased on the exchange or not. Regal Medical Group accepts Blue Shield coverage for employers and other sponsors, including Medicare.

They just don't take coverage under the ACA.

Regal Medical Group, by the way, is a for-profit concern. Their arrogance in this situation is enough to make me want to spread the word far and wide that greed is no substitute for compassion, particularly when their patients can pay.

http://crooksandliars.com/2014/08/regal-medical-group-refuses-all-covered?utm_source=dlvr.it&utm_medium=twitter