Michigan doc convicted of $6.3M Medicare fraud
A federal jury has convicted a Michigan doctor for her involvement in submitting over $6.3 million in fraudulent claims to Medicare for medically unnecessary orthotic braces ordered via telemarketing.
According to court documents and evidence presented at the trial, Sophie Toya, M.D., 55, of Bloomfield Hills, Mich. signed thousands of prescriptions for orthotic braces for over 2,500 Medicare patients during a six-month period. Toya was not the treating physician for any of these patients and, instead, was connected with some of the patients over the telephone through a telemarketing scheme and spoke to the patients briefly before signing orthotic brace prescriptions for them. For other patients, Toya signed prescriptions without having any contact with them.
The false prescriptions were used by brace supply companies to bill Medicare more than $6.3 million. Toya was paid approximately $120,000 in exchange for signing the fraudulent prescriptions.
The jury convicted Toya of one count of health care fraud and five counts of false statements relating to health care matters. She is scheduled to be sentenced on Aug. 15 and faces a maximum penalty of 10 years in prison for health care fraud and five years in prison on each of the false statements relating to health care matters counts.
Deft Research examines 2024 Medicare OEP switching and what it may mean for 2025
Medicare Advantage (MA) shopping and switching was widespread throughout the 2024 AEP and continued through the OEP, according to Deft Research’s 2024 Medicare OEP and Disenrollment Prevention Study, the company’ latest national market research report based on the survey of nearly 2,700 seniors in MA plans.
Indeed, the fall AEP experienced a seven-year high in MA switching (16 percent) and the winter OEP saw its highest level of switching (seven percent) since the OEP was reinstituted five years ago, Deft Research President George Dippel noted in the executive research brief that offered a high-level perspective on the study findings. Factors that drove switching included frustrations with flex cards, network changes, and the need for more supplemental benefits.
In 2025, drug coverage issues may cause MA members to check out other plans. Not every senior will pay attention to the changes outlined in the “Annual Notice of Change” (ANOC) they receive in the fall, and as a result, many may not know that their MA plan now comes with maximum out-of-pocket protections for prescriptions. “While seniors will like the fact that they will not face more than $2,000 in out-of-pocket drug costs from 2025 on, they may not like what that means for their premium, copays, or drug deductible,” Dippel said in the executive summary.
Dippel said that carriers should consider this as an opportunity to get ahead of the changes and find ways to communicate to members about plan changes. “Seniors need to hear the good, because sooner or later, they’re going to find out about the bad. For carriers to prevent an early drop in satisfaction and find success in 2025, they may need to explain both early ahead of the AEP,” he wrote.
CMS proposes organ transplant model for ESRD
The U. S. Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services last week announced a proposed payment model to increase access to kidney transplants for all people living with end-stage renal disease (ESRD). The model also aims improve the quality of care for people seeking kidney transplants, reduce disparities among individuals undergoing the process to receive a kidney transplant, and increase the efficiency and capability of transplant hospitals selected to participate.
The proposed model, which would hold kidney transplant hospitals accountable for the care they provide, would measure participating transplant hospitals by increases in the number of transplants, increased organ acceptance rates, and post-transplant outcomes. Hospitals eligible to be selected for the proposed model are non-pediatric facilities that conduct a minimum of 11 transplants each during a three-year baseline period. Out of the 257 transplant hospitals in the country, an estimated 90 would be required to participate in the proposed six-year model beginning January 1, 2025.
The proposal will be published in the Federal Register on May 17.
RAND report: Private insurers paid hospitals 254% of what Medicare would pay
A new report reveals the wide variation of the hospital prices paid by commercial insurers. Researchers believe the findings show that employers have opportunities to redesign their health plans and may help policymakers control health care costs.
Prices paid to hospitals during 2022 by employers and private insurers for both inpatient and outpatient services averaged 254 percent of what Medicare would have paid, with wide variation in prices among states, according to a new RAND report.
Some states (Arkansas, Iowa, Massachusetts, Michigan, Mississippi) had relative prices under 200 percent of Medicare, while other states (California, Florida, Georgia, New York, South Carolina, West Virginia, Wisconsin) had relative prices that were above 300 percent of Medicare.
Even as the number of hospitals and insurance claims analyzed has grown across multiple rounds of the RAND Hospital Price Transparency Study, the state-level average price has remained above 200 percent of Medicare—from 247 percent of Medicare prices in 2018 to 224 percent in 2020 and to 254 percent in 2022.
“The utility of this work is that it gives employers important tools they can use to become better-informed purchasers of health care services,” said Peter S. Hussey, director of RAND Health Care, in the study announcement. “Hospitals account for the largest share of health care spending in the United States so this report also provides valuable information that may aid policymakers interested in curbing health care costs.”
Spending on hospital services accounted for 42 percent of total U.S. personal health care spending for privately insured individuals in 2022, and hospital price increases are key drivers of growth in per capita spending among the 160 million Americans with private insurance.
Recent federal policies require hospitals to post prices for at least 300 “shoppable” services and that insurers post their full set of negotiated rates. However, many hospitals have not complied with these policies, and insurer-posted data contain duplicative information that often makes file sizes so large that they are difficult to use.
The RAND study found that in 2022 relative prices for inpatient hospital facility services averaged 255 percent of Medicare prices, outpatient hospital facility services averaged 289 percent, and associated professional services averaged 188 percent of what Medicare would have paid for the same services.
Prices for common outpatient services performed in ambulatory surgical centers averaged 170 percent of Medicare payments.
“The widely varying prices among hospitals suggests that employers have opportunities to redesign their health plans to better align hospital prices with the value of care provided,” said Brian Briscombe, who currently leads the RAND hospital price transparency project, in the announcement. “However, price transparency alone will not lead to changes if employers do not or cannot act upon price information.”
The report explains that very little variation in prices is explained by each hospital's share of patients covered by Medicare or Medicaid. A larger portion of price variation is explained by hospital market power.
The RAND study is based on information about more than 4,000 hospitals in 49 states and Washington D.C. from 2020 to 2022. (Maryland is excluded from the analysis because it long has had a system in place where the privately insured and Medicare recipients pay the same price.)