PUBLIC POLICY - Position and Information
Greater Minnesota Health Care Coalition
Public Policy Briefing Memo on:
Health Insurance industry Transparency and Accountability
The issue of health insurance transparency and accountability, especially for programs funded by taxpayer dollars, is very important. It relates to large sums of money paid to HMOs but improperly withheld from medical providers, resulting in unwarranted excess profits, huge financial waste, and in some cases, inadequate care to the low income enrollees of public health care programs. Another aspect is falsified claims of enrollees’ health, resulting in excess payments and profits. Reducing and returning this wasted money to government budgets can help alleviate the underfunding of other needed programs, and/or help moderate the need to increase taxes.
This set of issues has policy aspects at the federal, state, and county levels:
A. Federal policy
Medicare Advantage overpayments:
The Center for Public Integrity reports that tens of billions of dollars have been wasted, with about $2 billion a year at present, according to the GAO (Government Accountability Office). Many of the insurance companies which control this huge program of privatized Medicare file false reports claiming that their enrollees are sicker than they are, and thereby automatically get larger payments from the government than warranted.
Oversight is minimal, and the federal agencies appear to have neither the will nor the resources to deal with this massive problem. The insurance companies have enough clout in Congress to push back attempts to rein in windfall payments, fraud, waste and abuse. The federal government is unwilling to release the insurance companies’ actual payment and financial data.
B. State policy
1. Disclosure of secret HMO payment rates to doctors and hospitals:
The legislature began debating in 2014, and will have to finish in 2015, whether the prices that HMOs pay doctors and hospitals for the state’s public programs should be made public or not. In 2014, a one-year delay was granted for the HMOs to comply with a new requirement that this data must be public. The state has never required the HMOs to reveal their data in its contracts. The HMOs claim that doing so would result in their having to pay the medical providers more, and in return require bigger infusions of tax dollars. The state Dept. of Human Services (DHS) will examine this theory and issue a report by year’s end. Disclosure, once it is required, may reveal that the HMOs have paid medical providers much less than the HMOs attested to state agencies. If so, this would expose a large source of wasted taxpayer dollars. It could lead to reductions in per-person public expenditures, and reduced premiums for individual and small business insurance policies.
2. State audit of HMO expenses for public health care programs:
The state never conducted any outside audits to determine what the HMOs actually spend for medical care, out of the billions of taxpayer dollars given to them each year. The legislature decided in 2012 that its first-ever audit would be conducted, to examine calendar 2014 expenses. This year, however, the Office of Legislative Auditor asked the legislature to change the statutory mandate, so that the audit would be performed in-house instead of hiring an outside auditing firm; and to remove the requirement to determine whether or not any laws had been broken. This proposal was not debated and did not pass in 2014, but another attempt might be made in 2015.
3. State use of actual payment data to set payment rates to HMOs:
In addition to not having the HMOs’ payment data be public, and never conducting an outside audit to verify those expenses, DHS has never used actual payment data in its own calculations to set its per-person payments to the HMOs. Instead, it used summary numbers supplied by the HMOs. This has been shown, by the Segal report and others, to have resulted in hundreds of millions of dollars in overpayments. The overpayments end up as excess profits and excess financial reserves.
In 2011, DHS started receiving this data, known as “paid claims encounter data” from the HMOs for the first time. However, as of 2014, DHS is only using actual data of medication expenses in the HMO rate setting -- and still not the data for doctor and hospital expenses.
The legislature could intervene to demand answers and make public why this is so, and to require DHS to start using that data in specific ways to set the rates. The HMOs’ self-reported profits from the state programs are three times what they are supposed to be, which can be an indication that overpayments are still occurring.
4. Unused auditing powers; recovery of past overpayments:
The state has auditing powers that it could have used already, and still can use, to determine the extent of past and present overpayments. Such auditing of the “integrity” of the financial data of medical payments could reveal that the HMOs had intentionally inflated the amounts that it said it paid doctors and hospitals. If so, then they could be forced to return these amounts obtained under illegal, false pretenses. Potentially, a half billion to a billion dollars could be recovered, with half of the money being returned each to the Minnesota and federal governments. The U.S. Dept .of Justice is currently conducting its own investigation to look into this precise matter.
The state has three potential ways to do its own audits and investigations:
(1) The Governor’s administration has statutory power, for the Dept. of Health, of conducting an
audit of the HMOs’ finances whenever the public interest merits it, and charge the cost of the
auditing to the HMOs themselves. This power has never been used, but the current situation
warrants that it should be used, given that such an audit could discover fraud and recover
hundreds of millions of dollars for the state’s general fund.
(2) The State Attorney General has powers to conduct its own investigation into possible Medicaid
fraud by the HMOs; and also has additional oversight powers over two of the HMOs which are
501 c 3s: Group Health, and UCare.
(3) The Financial Crimes Task Force, housed in the MN. Dept. of Public Safety, has investigative
powers. The state legislature has some oversight authority over this Task Force.
C. County policy
1. County-run managed care public health coverage programs:
Counties have an option under state law to directly operate the state’s low income health care programs, instead of the state contracting with the HMOs. This provides local control, better administrative efficiency, better services to enrollees (especially dental), positive partnerships with local health care providers, financial transparency, and public accountability. 26 rural counties are already doing this. It can potentially be expanded to provide low cost coverage to local businesses and individuals who are not in the public programs. County boards can consider creating their own system; collaborating with other counties; or joining one of the existing systems.
2. Ramsey County: Unnecessary payments to Regions Hospital:
Ramsey County makes large, voluntary payments to Regions Hospital, on the theory that it is needed to help cover the cost of treatments for indigent county residents. Those expenses have never been audited. The County relies on the self-reported figures from HealthPartners, which owns the Regions Hospital business. If the expenses were audited, it might show that Regions/Health Partners has been over-billing the County. This could result in a halt to the payments of county funds, and maybe to the recovery of past payments. The County could obtain an audit by requesting the MN State Auditor to do this. However, the Ramsey County Board has not requested this, and continues to make payments.
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For more detailed information and further explanation on these policy ideas, contact:
Greater MN Health Care Coalition (GMHCC), 47 Park St. N., Mora, MN 55051 1-888-694-5055
Or email Buddy Robinson, GMHCC Co-Coordinator: firstname.lastname@example.org
from: Buddy Robinson 6.4.14
BREAKING: A battle is looming over Health Plans' secret price data!
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Who's getting rich on the backs of seniors?
read the report from the Center for Public Integrity
Popular Stories... Informative Links
Our method of healthcare delivery in the United States is fragmented, confusing and unsustainable.
If you want to know how our healthcare♥ "system" doesn't work, you need to watch this:
* Healthcare Accountability Press Conference *
GMHCC held a press conference on Wednesday March 27th at 11 a.m. in Room 125 of the State Capitol building. The purpose of the press conference was to update the media about progess and updates in our investigative efforts on HMO and DHS accountability in healthcare. It's a follow-up to the release of our 20 page Healthcare Accountability/Transparency report. It covers and documents over 15 years of HMO mismanagement of a $4 billion dollar per year income which is funded by your tax dollars.
The press conference summary report can also be viewed on the KSTP-TV site here:
AND you can...
"Who Was Minding The Store?" >>>>>>>>>>>>>>>>>>>>>>>>>
A report on Minnesota’s problem with contracting out the state public health care programs to HMOs
ALSO, you can...
HHS Accountability Legislation Lacking…
June 15, 2012
After many hours of debate and legislative wrangling over the provisions of what has become generically known as the Health & Human Services (HHS) Accountability Bill, the final version’s elements can now be revealed.
This information comes courtesy of a private researcher and ally of GMHCC and Seven County.
contained in HHS omnibus legislation
First introduced in various stand-alone bills, managed care audit requirements were folded into the 2012 Health and Human Services Omnibus bill, which emerged from conference committee on April 23rd.
The audit provisions alter Minnesota Statutes section 256B.69, by adding another subdivision, labeled (9d.). This subdivision allows that:
• The legislative auditor will contract with an outside audit firm to conduct a bi-annual, “independent, third-party financial audit” of managed care financial data.
• Audits will focus on data that HMOs and county-based purchasers already submit to DHS – including information on administrative expenses, revenues, reserves, reinsurance, and more.
• Audits will be conducted “in accordance with generally accepted government auditing standards issued by the United States Government Accountability Office.”
• The audits will determine if managed care programs are compliant with state and federal laws, as well as with the federal Medicaid rate certification process.
• Firms retained for the audit cannot have provided services to managed care or county-based purchasers during the time period for which the audit is being conducted.
• Future managed care contracts must include provisions that allow auditors access to relevant information, and stipulate cooperation with such auditors. Contracted firms will have the same powers as those of the legislative auditor, for the purposes of completing managed care audits.
• Managed care organizations must provide DHS with bi-weekly “encounter” and “claims” data on public health care programs.
• Audit results will be circulated to the Commissioner of DHS, the state auditor, the attorney general, and various members of the legislative leadership.
The end result of these changes is one long-sought by transparency advocates. The bill adds an additional layer of oversight to the state’s managed care programs, by inserting an external auditor who is empowered by (and answerable) to Minnesota’s legislative auditor.
Previously, the oversight of managed care programs fell to DHS, and to a lesser extent, to MDH and the Department of Commerce. The underlying premise of the audit legislation clearly appears to be that an outside observer can find new perspectives on the efficacy of public health care plans, even though they will be using the same underlying data set as state agencies.
The legislation omits a key provision sought by Senator John Marty, in that audits will only extend to contracts beginning in 2014, and will not be retroactive to prior years. GMHCC has long contended that understanding what occurred in the past will be critical to managing public programs going forward – as well as discovering the scope and scale of any past improprieties. There is some hope that language can be added or amended next session to move the audit window back at least to 2011 or before. ~30~
In a move that caught many people by surprise, the attorney for almost 30 years for the MHA (Minnesota Hospital Association) was abruptly terminated in response to a video that he helped produce.
The video was authored and produced by Dr. David Feinwachs who has been the corporate attorney for the MHA since 1980. Feinwachs was “released” from responsibilities in late November in apparent response to vehement objections to its content by various HMOs in Minnesota. Minnesota’s HMOs were the subject of the video along with the state healthcare programs that they have been allowed to run since 1983.
At issue in the video is the double-standard and lack of accountability that is now the rule for the non-profit HMOs in Minnesota (by law, all Minnesota HMOs are required to be organized as non-profit entities). Feinwachs describes the accountability problem as a “black box.” State “tax dollars go into the black box” of HMO accounting in the form of $3 billion dollars in tax money every biennium, and they are “never accounted for” in any meaningful way, according to Feinwachs.
Feinwachs considers the current system of handing over healthcare tax dollars to the HMOs fiscally irresponsible and something that needs fixing.
The video illustrates the lack of oversight in a simple and understandable fashion and asks viewers to consider the question of why no accounting of funds has been demanded for these tax dollars, and why this *demonstration project has been allowed to continue unmonitored.
The response to the video’s content from the HMOs through the MN Council of Health Plans (MCHP), the organization which is made up of HMOs in the state, has been that they are monitored and are accountable to the state.
Feinwachs addresses that by saying they (the HMOs) are allowed to self report their expenditures and they don’t follow the same standard as any other group receiving state tax dollars. He goes on to say that they are also not subject to any competitive bidding process, which is also unique to organizations receive state money.
As a well known and highly respected member of the healthcare industry as part of the MHA, Feinwach’s firing has generated a huge amount of interest. Related to that, KSTP-TV reporter Jay Kolls has done an investigative piece on the story and plans to follow legislative activity related to the issue of HMO accountability.
Seven County and the Greater Minnesota Health Care Coalition (GMHCC) has contended for years that turning over state run programs without regulations or accountable standards has always been a huge waste of state resources. Efforts to urge accountability hearings have been an ongoing priority with GMHCC and its coalition partners for years.
State “tax dollars go into the black box” of HMO accounting in the form of $3 billion dollars in tax money every biennium, and they are “never accounted for...”
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Welcome to the Greater Minnesota Health Care Coalition.
GMHCC is a non-profit organization, grassroots organization. We seek to unite Greater Minnesota citizens and their organizations to create positive social change on healthcare and other issues. In particular, we advocate for affordable prescription drugs, a sustainable Medicare system, and healthcare for all citizens. We also offer related information and resources, including a prescription drug program.
Follow our links to learn more about our positions on issues such as Medicare, healthcare, and prescription drugs; our legislative outreach, and our prescription partnership program. If you want more information or would like to talk with someone at GMHCC, call us toll-free at 1-888-694-5055.