United Probe Expansive
The U.S. Justice Department’s (DOJ) criminal division investigation into UnitedHealth Group has been bigger from the start or has expanded. Latest reports suggest that the company is under investigation into both how it reimburses its owned doctors as well as its pharmacy benefit’s manager’s (PBM — OptumRx) business and billing practices. Previously, it was reported the DOJ was investigating alleged Medicare Advantage (MA) risk adjustment fraud.
In the past, I have talked about how federal regulators might go after vertical integration in the healthcare industry and United is the biggest example. Vertically integrated companies are alleged to unfairly inflate price/cost and skirt the minimum medical loss ratio (MLR) rules by having non-arm’s-length agreements with their related companies to keep revenue and margin within the overall enterprise. Could the PBM and physician investigations be touching this concept? It could also be the case that the incentives given owned doctors as well as other pricing and relationships by the PBM violate fraud and other laws.
Additional articles: https://www.modernhealthcare.com/insurance/mh-doj-unitedhealth-optum-rx-medicare-billing/ and https://www.fiercehealthcare.com/payers/wsj-report-doj-interviewing-former-employees-about-medicare-billing-practices-unitedhealth
#fwa #unitedhealthcare #medicareadvantage #doj #antitrust
Phantom Obamacare Enrollees
I have discussed the potential fraud in terms of Exchange enrollment. Whatever one thinks of coverage expansion, enrollment fraud should not be countenanced. Investigations are occurring into the fraudulent enrollment schemes by brokers and agents to garner Exchange commissions. Recently, the Centers for Medicare and Medicaid Services (CMS) released data that shows a surge in members with no claims in the Exchanges. It is not definitive by any means, but it certainly lends credence to the argument that a great deal is awry and perhaps the current framework of premium and cost-sharing subsidies, along with premium subsidy enhancements set to expire this year, may play a role. Did the premium enhancements increase fraudulent enrollment because so many more people did not need to pay a premium? And is there underlying fraudulent enrollment in the system?
The influential Paragon Health Institute has published a review of the issue, along with a summation of the CMS data. Paragon declares these folks as phantom enrollees. A few highlights:
- The number of Exchange individual market enrollees with no medical claims more than tripled from 2021 to 2024. Nearly 12 million enrollees had no medical claims during 2024. That is equal to 8 million enrollees on an annualized basis.
- The percentage of individual market enrollees with no claims jumped from fewer than 20 percent in 2021 to 35 percent in 2024—an increase of nearly 80 percent in three years.
- About 40% of those enrolled in the 94% actuarial value cost-sharing subsidy Silver plans and bronze plans had no medical claims in 2024.
- The rise in phantom enrollees is absent in the small-group market.
- This explosive growth in phantom enrollees matches patterns Paragon has documented for more than a year.
#aca #obamacare #exchanges #marketing #fwa #enrollment
— Marc S. Ryan
