Health "Care" Fraud Bust: By The Numbers

Courtesy ForAmerica:

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It's Time To Fully Implement Obamacare

Enough of the BS already. Obamacare can't and won't be repealed without 60 votes in the Senate. Any Republican alternative claiming to replace Obamacare that takes away money from states won't pass either. Instead of trying to do the same thing over and over while expecting a different result why not simply implement what President Obama signed back on March 23, 2010?

Members of Congress - on both sides of the aisle - have two objectives, protect themselves and find a way to get reelected. Full implementation will put both of these objectives at risk.

Want to know the perfect place to start? Eliminate Congress' illegal status as a "small business" and force all 12,000+ members, staffers, and their dependents to purchase insurance legally as the law was written. Anything less would be uncivilized.

BREAKING: Potential Reprieve for Baby Charlie

"US doctor will travel to UK to assess ill infant"

That's the good news. The not-so-great news is that he isn't scheduled to head there until next week, so who knows if Charlie will still even be alive then.

Still, small miracles...

A Tale of Two Health Systems…

It was the best of times; it was the worst of times in the area of Medicine for two countries.

One country had a health system that was based on the capitalistic principals of supply and demand. Because of the entrepreneurial system, Medical Care was valued around the world, as long as you could afford to pay for the privilege. This country will be called Callous.

In another country, the populace trusted their government with their Healthcare. No one went without the basics, but due to finite resources, not all could receive treatment. Compassion came with recognition that some will die so others may live. This country was called Enlightened.

Into these countries came two sick little boys that highlighted the successes and failures, the winners and losers, in Medicine today.

The first little boy is named Ethan. Ethan is a precocious 3 year old boy, the delight of his parents.

“Ethan was born with a congenital heart defect known as Heterotaxy syndrome. It means he has already undergone multiple open heart operations, and will likely need more to keep him alive.”

Little Ethan has endured many surgeries for his condition and takes daily medications to keep him alive. His latest surgery resulted in a bill of $231,115.00.  Since his parents had health insurance, their financial responsibility was only $500.00 and thanks to the parent’s health insurance, little Ethan is assured of receiving medical treatment for the remainder of his life.

The other little boy is Charlie. Charlie is 10 months old and was born with Mitochondrial Depletion Syndrome. Charlie is very sick and has not received any treatment, other than basic life support. Without life support he will die and even with treatment, the prognosis is not good.

Now one boy lives in the country that has Health Care that is each individual’s financial responsibility and the other boy lives in the country that takes cares of its populaces Health Care without a financial drain on the individual.

Reading the scenarios, Ethan is fairing much better than Charlie. He is receiving treatment and living and thriving. Ethan lives in the United State of America and has the benefits of all the Medical Care he could want or need, without the government interfering in his decision. Charlie lives in England, where the Health Care is directed by the National Health Care System, which determines how the medical dollars will be spent and on whom, without input from the patient.

Which country is which from our opening? …. Well Dear Reader, I am sure you have figured out that Callous is the USA and Enlightened is England.

These two cases focus in real time the benefits of the Health Care System in America and the flaw in any Socialist Health Care (such as that which currently exists in England. In any Socialist System, there is INFINITE NEED with FINITE RESOURCES. England has chosen the compassionate route for Health Care, taking the financial burden from individuals so all can benefit. The only problem is that when there is only one pot of money then only the strong will survive. When individuals rely on themselves, instead of the Government, then there are INFINITE RESOURCES to deal with all needs.

There is a footnote to these stories: Ethan is lucky enough to have one parent who is an American and one parent who is Canadian. Given the choice of the two health systems for Ethan’s care, his parents picked America. They purposely chose Callous over Enlightened.

Burning Data

We've been writing about who owns our medical data for a long time. For example:

"Hugo Campos has [an ICD] buried in his chest to help keep him alive. But he has no idea what it says about his faulty heart ... what if Mr Campos wants to see that data for himself?"

An interesting question, no?

Here's another: what if that information was relevant to a crime?

Think that's far-fetched?

Well, thanks to FoIB Holly R, we have the case of Ross Compton:

"A judge says data from the pacemaker of a man accused of setting his Ohio house on fire in 2016 can be presented as evidence at his trial."

His attorney had argued that use of the data "violated Compton's constitutional rights."

Maybe, but the judge didn't agree, saying that "the individual data is no more private than other things."

What "other things" isn't clear, but the message certainly is.

Tuesday LinkFest

■ First up, courtesy of FoIB Holly R:

Just released USA Today poll on Obamacare:
11% keep it
42% fix it with major changes
44% repeal

— Ben Ferguson (@benfergusonshow) July 10, 2017

■ Next, our friend Allison B at ThinkAdvisor piles on:

"Individual Health Enrollment Falls 11% ... Plan withdrawals and rising premiums led to a sharp drop in individual and family major medical plan use in the first quarter" of the year.

But hey, if you like your plan....

■ And finally, FoIB Ʀєfùsєηíκ tips us that "The number of U.S. adults without health insurance has grown by some 2 million this year."

Which seems unpossible, since the entire point of ObamaCare was to eradicate this plague.

Hunh.

SEP News (Sorta)

As we've previously noted, the qualification process for triggering a Special Open Enrollment has gotten tougher, as carriers have been hit with ever higher claims:

"Perhaps the most egregious is the fact that no one in government seems to care about the massive fraud being perpetrated right under their noses during this time."

Our friends at Medical Mutual emailed us a slideshow of the new, tougher Special Open Enrollment process, available here.

One that immediately jumped out was this:

"Beginning in Summer 2017, new applicants ... who attest to certain types of SEP qualifying events will be subject to the SEPV process of pre-enrollment verification. Eligible consumers must submit documents that confirm their SEP eligibility before they can enroll and start using their Marketplace coverage."

Quite different than before, where one was given a certain period of time after enrolling in (and, perhaps, using) a new plan. Under the new system, no policy is issued until the verification paperwork is submitted and approved.

Which would seem to be a challenge for carriers, but fret not:

"When submitting business ON Exchange please submit verification documents directly to the exchange.  Medical Mutual cannot process/accept anything that is submitted directly to us."

Can't say as I blame them. 

NB: I reached out to our rep who confirmed that MMO would continue to process this info for off-HIX plans.

Stupid "Beneficiary" Trick

A few years ago, we reported on a "widow" who tried to collect on her husband's life insurance policy. The challenge? He wasn't dead, and the woman was charged with fraud.

But at least the perp had her paperwork in order.

Not so with this rocket surgeon wannabe:

"A newlywed accused of soliciting her firefighter husband's killing to collect $100,000 in insurance money has been convicted of aggravated murder in a scheme that was flawed from the start: His ex-wife was still the beneficiary of his policy."

Ooops.

Oh, and it gets better (for certain values of "better"): she'd recruited her teenaged daughter and her boyfriend to do find a someone to actually do the deed.

But wait, there's more:

The boyfriend thought it'd be a good idea to "keep it in the family," and reached out to his cousin to pull the trigger. Be sure to click on over for even more twists.

Breaking: A Reprieve for Baby Charlie?

Via RedState:

"In an abrupt shift, a London hospital said on Friday that it would reconsider its decision to turn off life support for Charlie Gard, a brain-damaged and terminally ill British infant, in light of “fresh evidence” about a potential treatment."

More as (if?) this develops.

From the Mailbag: CTE or no CTE?

Interesting query from a reader:

"My sister went to the doctor because of some symptoms she's been having (memory loss, moodiness and headaches). She's a cyclist, and used to race competitively, and suffered concussions in the past. The doctor thinks she could possibly have CTE. She hasn't done any testing because from what she knows there's no treatment for it.

She does have health insurance through her spouse's employer, but wants to know if she gets this testing and it's in her records that she has CTE could that hurt her in the future for insurance purposes? Like if she has to switch insurance companies etc.

I know right now it wouldn't matter because of ACA. But what if things change if/when they repeal it? The way I always understood pre-existing conditions before ACA was that you could not have a gap in coverage. So if you have insurance and you're diagnosed with a condition you are covered. If you switch insurance and there is no gap in coverage it can't be considered a pre-existing condition. But if you do have a gap in coverage it could fall under pre-existing conditions. Is that how it worked before? Who knows how insurance is going to change in the future. She's just trying to figure out if she should just not do it and wait and see."

First, Thank You for a really outstanding, well thought out query. There's a lot to unpack, so I'll try to be as thorough as possible.

Here's the thing: we really don't know what's going to happen (or when, or even if) ACA-wise. If we go back to something that looks like pre-ACA, then yes, this is a legitimate concern. But the cat's already out of that bag:

"went to the doctor because of some symptoms she's been having"

Assuming new applications look like pre-ACA, then she's going to have to answer yes to at least one of the questions ("have you consulted a physician"). It may not be explicitly CTE, but it's likely going to be an issue, although I have no idea how much of one. But: this presumes a new app. Again, assuming something that looks like 2009, as long as she keeps continuous coverage group-to-group (or COBRA), no problem. However: that only really worked individual-to-group, or group-to-group, not group-to-individual (or individual-to-individual).

From what I've read, CTE is kinda like Alzheimer's in that it's only truly diagnosable at autopsy. While alive we're only able to infer its presence. So test or not? I don't know, but I would suggest taking the insurance element out of the equation, and look only at pro's/con's of "knowing."

Hope this helps, and best of luck to your sister-in-law and her family.

Thursday Afternoon Potpourri

■ Our friends at Cornerstone have an update and explanation of the Social Security Number removal initiative (SSNRI), part of 2015's "“Medicare Access and CHIP Reauthorization” (MACRA).

The bottom line is that CMS will begin issuing new kinds of ID for Medicare beneficiaries, in an effort to hold down identity theft.

Also known as: major headache for providers.

■ As co-blogger Patrick reported this past Spring, the Small Business Health Options Program (SHOP) has been a resounding .... flop:

"Turns out SHOP enrollment is extremely cumbersome, there are less plan options compared to the off exchange market, and that tax credit, well it hasn't been worthwhile for most employers"

Ooops.

Well, the folks at Medical Mutual just emailed us to say "adios,muchachos:"

"Beginning January 1, 2018, Medical Mutual will no longer offer plans through the Small Business Health Options Program (SHOP) marketplace. Coverage will terminate for affected groups on their renewal date."

But hey, if you like your group health plan...

■ From the "You Don't See This Every Day" Department:

"Zurich American Life Insurance Company is offering to buy back some of its annuity contracts ...  it is making the offer partly because it believes some annuity holders' needs may have changed over time, and partly because it wants to exit this segment of the variable annuity business"

To sweeten the deal, they're offering an "enhancement amount."

Hunh.

Bad news: A P&C case study

Our friend Jeff M sent along the link to this sad story:

"Owners and renters in North Carolina say they were left in the dark after a beach condominium community suddenly shut down. The condos were condemned Friday, after an engineering report found that the property has dangerous structural issues."

It's not clear whether the owners will be allowed to retrieve their personal property.

Okay Henry, that is a sad story, but what's the insurance angle?

Well, Jeff asked if the owners' condo policies would cover this situation. As usual in these cases, I turned to our good friend (and P&C guru) Bill M. Now keep in mind that his answers are specific to Ohio, but that it's likely that they'd also apply in other states.

Basically, the owners are out of luck.

Now, why is that?

Well, Bill taught me a new phrase, and suggested I use it whenever I'm looking at these kinds of (potential) claims: "cause of loss." That is, which circumstances are specifically covered, and which are specifically excluded.

So here's the relevant exclusion:

(4) (a) wear and tear, marring, scratching or deterioration; (emphasis added)

So the "cause of loss" is specifically excluded. Which is a double whammy: the owner now has no place to live, but the bank still wants their mortgage paid off, and there's not going to be a check from the insurance company to pay off the old place, or pay for a new one.

But what about their personal property (clothes, appliances, furniture, etc)? Well, they're likely outta luck there,  too:

(1) Enforcement of any ordinance or law regulating the construction, repair or demolition of a building or other structure, unless specifically provided under this policy

The "cause of loss" here would be the government forbidding the owners to retrieve their belongings. So again, no insurance to pay for replacing them.

Yikes.

Medicaid Fact-Check

Over at The Apothecary, Chris Conover makes a solid case that the ACA's Medicaid expansion doesn't actually save lives.

Now, we already know that the ACA itself has a body count:

"Mortality Rates ... equivalent to an excess 11,000 annual U.S. adult deaths relative to the pre-Obamacare steady state trends"

But Chris goes even further into the mess; he demonstrates that "the weight of the scientific evidence is that Medicaid expansion has not saved lives." Granted, that's not quite the same thing, but it certainly puts paid to the claim that folks are better off under Medicaid. He does this by looking at how many folks will likely lose coverage under the AHCA/BCRA (and what kind), and then unpacks the actual numbers which the Center for American Progress appears to have, well, misrepresented.

I really suggest reading the whole thing, but this piece is too good not to post:

"[UC San Diego’s Richard Kronick] found no statistically significant difference in the mortality risks faced by people who were uninsured compared to those with private coverage:"

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Buy-Sell: The Video

We've discussed buy-sell agreements before (here, for example. And here), but recently Illinois Mutual posted a really helpful video explaining how they work, and why they're so important:

More on Baby Charlie? Yes. Much more. And you need to know it.

I think Charlie Martin's linked report here is the best of many I've seen on this terrible situation - because Martin provides specific facts and steers away from emotionalism found in previous reports.

I've also been thinking about similarities between baby Charlie and the Nataline Sarkisyan case of a few years ago.

The unfortunate Nataline was on life support; heroic medical treatment had already been tried; and independent doctors who reviewed her situation unanimously recommended against an organ transplant as too risky. In short, there was no assurance that further treatment would make any difference. Martin’s article provides details that show baby Charlie's condition is somewhat similar to Nataline's: on life support; physicians advise that further treatment is futile; following further appeals, the NHS hospital denies further treatment and recommends baby Charlie be allowed to die with dignity.

So . . . is that the end of the story for, and about, baby Charlie Gard? No.  I don't think so.

Apart from the human tragedy here I think the central outrage in baby Charlie's short life remains that NHS and the power of the bureaucratic state brushed the family aside and is making all the decisions - in the process, keeping the child and his parents virtual prisoners of NHS.  Martin's linked article reports that

"His parents then asked to be able to take Charlie home, so he can at least die at home. That was refused too. I haven't seen any reasoning for that; it's hard not to think they're suspicious his parents wouldn't let Charlie just die as directed, but would, immediately upon regaining control of their son, flee the country."

Probably true. They have the money. And as for Great Ormond Hospital's suggestion to let the baby die with dignity - if keeping an infant prisoner in a hospital is the Hospital’s idea of dignity, it can bite my shiny metal #ss.

Note: nearly the same thing happened in my own town, to neighbors of our in-laws whose daughter was also diagnosed with mitochondrial disease. And then the hospital and bureaucrats in the State of Massachusetts took over and tortured the whole family for years.  

Do not overlook that in these cases, private insurance and government insurance behaved in the same ways. People who say nothing like this can happen here are seriously misinformed. It has already happened here. People who say nothing like this can happen with a nationalized insurance scheme are living in a dream world. These situations will surely arise again in the U.S. even if we end up with some kind of government single-payer medical welfare scheme.

The Baby Charlie Story & Your Healthcare

As co-blogger Mike wrote about on Wednesday, 10 month old Charlie Gard has lost his fight:

"The parents of terminally-ill baby Charlie Gard are 'utterly distraught' and facing fresh heartbreak after losing their final appeal in the European Court of Human Rights."

And, as Mike pointed out, there is true irony in the court's name.

But it's his conclusion that I think needs to be magnified:

"It would not be different in America."

Here, Mike's referring to that ultimate progressive utopia: a government-run, single payer health care system. And this is the true moral of little Charlie's story: it's clearly not about the money, but has always been about control.

How do we know this?

Very simple: they explicitly told us.

Hunh?

Well, go back and read the Daily Mail story that Mike linked. Charlie's parents weren't asking for special care, or special funding, or that the Much Vaunted National Health System© (because ultimately, they own this) do anything more than get out of the way. They had already successfully raised almost $2 million in order to take him to the US for a promising therapy trial. It would have cost the MVNHS© (and the European Court) exactly nothing to let him go.

Well, that's not entirely true: because if they let Charlie go, well, Katie bar the door.

It's all about control. And if you like the idea of the IRS (for example) deciding who gets care - and who doesn't - well, be careful what you wish for.

Honey, I shrunk the market

Still think you can keep your plan?

First up, FoIB Jeff M alerts us to this news:

"95 percent of N.C. counties expected to have just one ACA insurer next year"

Adding insult to injury:

"Blue Cross and Blue Shield of North Carolina announced that it has filed for a 22.9 percent rate increase"

Next, FoIB Holly R tips us that "Premier Health plans to exit Ohio's federally funded health insurance exchange." They're sticking it out, though, in the off-Exchange market.

For now.

#ACAWinning

This Sceptered Isle Part MCVII

At some point, the state legal system, not the family, will decide whether further care will be permitted - even if the family has raised the money to continue treatment. 

"The ECHR (European Court of Human Rights) announced the application to the court by the parents was 'inadmissible' and added that their decision was 'final'.

Court of Human Rights,  eh?  Take notice.  This is what "human rights" means, in a government, single payer medical insurance scheme.  

It would not be different in America.

Something Different

Early in my career, before I decided to focus solely on the life/health side of this business, I got my Property/Casualty license and sold a few home and auto policies, and one batting cage plan.

Hunh?

Well, one day a call came in from a person who was planning on opening a batting cage business, and needed help with the liability. Since I was still pretty much a newbie who didn't know any better, I said "sure!"

Then I went looking for a carrier.

Turned out that (at least in the mid-80's) batting cages are a big problem from a liability standpoint, and none of our carriers would even quote it. So I turned to what's called the "excess market," and was able to secure coverage through an arrangement with Lloyd's of London (really!). As I recall, it wasn't a particularly high dollar case, but it was certainly an eye-opener.

Since that time, I no longer dabble in that side of the business, and don't really have any need for a LLoyd's connection. But that doesn't mean that the famous firm doesn't have a place on this side of the business. This morning, FoIB Jeff M sent me a link to a very interesting article about how Lloyd's was able to help a successful investment firm arrange for $50 million of key man disability insurance. This type of plan pays the business if the executive becomes disabled. It isn't ubiquitous, but it's also not unheard of. The challenge is in the amount at risk: $50 million is a lot of coverage, and the firm's regular insurance folks had to turn to LLoyd's to fulfill the order.

Anyway, it's a very interesting case study that proves the old saying (which I made up years ago) that you can insure anyone for anything .... if money's not an object.

Wednesday LinkFest

■ From the Oy, Canada! Department, our friend WeirdDave alerts us to a report on how that free health care's working out for our Neighbors to the North©:

"Canadians who need medically necessary surgeries waited longer than ever for treatment"

And the average was about 5 months! But hey, free.

■ And speaking of "free" health care, our friends across The Pond prover once again that government-run health care schemes are no bargain:

Why not have a government-funded single payer health care system like they do in Europe? Here's why:Europeans pay for it with enormous taxes pic.twitter.com/GyTg2b8pmH

— Robert Zubrin (@robert_zubrin) June 23, 2017

■ And finally, you just know that ObamaCare's in free-fall when a high profile Democrat congresscritter explicitly admits it on camera:

[Courtesy WeaselZippers and FoIB Rich W]