The FBI asserts that “Health care fraud costs the country tens of billions of dollars a year. It’s a rising threat…” https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud. Yet Obamacare is based on squeezing consumers for every penny and “forgiving” waste by insurers and government that pay out on fraudulent provider billing and claims. (consumer fraud is estimated at under 10 percent of all fraud).
One of my persistent objections to Obamacare is its hyperfocus on saving government dollars by squeezing consumers. From the forced purchase of health insurance to the forced micromanagement by providers who are rewarded with money for cutting down on expensive services, “the value model” that neither saves patients money nor clearly improves patient outcomes because it focuses on among other things discouraging treatment for the sickest among us least likely to have a positive outcome, that leaves many of us answering surveys and consenting to nanny phone calls by third parties who are part of a widening network of folks butting into our medical records, to adding tiers of barriers to obtaining medical authorization and insurance company authorization...Even as we PAY MORE Obamacare discourages the obvious...Insurers and government standards for going after and recovering fraudulent dollars paid out.
Remember, the FBI asserts that “Health care fraud costs the country tens of billions of dollars a year. It’s a rising threat…” https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud, yet insurance company after insurance company advises how YOU (you and I, the consumer) can help fight health care fraud.
Read through any search of medical fraud and you’ll find that from the federal government to insurance companies we, the consumers, are told what we can do to help to fight fraud.
Really? Why would insurance companies enlist our help for something that is worth “tens of billions of dollars a year”?
They certainly haven’t consulted us on value based care that is shuffling around and rating our outcomes and how efficiently providers are focusing on treating patients with a better chance of a better outcome in order to get federal money as a reward for such push-throughs. As a matter of fact, they’re embracing programs to have people call us to remind us to take our meds, stop eating the wrong foods or telling us how our odds make us unworthy of available treatments based on cost. Yet we’re entrusted with “fighting fraud”?
It’s the smallness of Obamacare that has dramatically worsened the situation with the medical loss ratio 80-20 (or 85-15) rule the Affordable Care Act put in place that prohibits insurance companies from including fraud investigations as part of their justifiable 80 percent costs so that those expenses would be considered part of the administrative costs that if they exceed 20 percent would have to be refunded to consumers.
(Not surprisingly for anyone who has seen a provider lately, the 80 percent pass for insurers includes money spent on medical care and "quality improvement activities," like health hotlines, which are proliferating fast.)
Obamacare DISCOURAGED insurers from going after the tens of billions of dollars in insurance fraud by requiring that the expense of finding those dollars by insurers would count towards the 20 percent permissible for administrative expenses.
Was there nothing else that could be done? Of course there was. Switch up the quality improvement steps, the value steps that are often only valuable to insurers’ bottom lines with preventing and prosecuting fraud. Or, how about requiring that companies that fail to recover a certain dollar amount of fraudulent payouts have to pass that money back to consumers? Or how about providing for money rewards to consumers who discover fraud? But that’s not Obamacare which focuses on a single approach towards consumers…THE THREAT.
Now, dare we ask? Why is Obamacare that fiercely went after consumers as the healthcare “problem” and therefore opted to force everyone to purchase health insurance or face a money penalty, that raised the amounts we pay out-of-pocket in money for copayments, coinsurance, deductibles and premiums, that supports bottom-heavy coverage of the healthy for things like checkups while leaving those in need of medical care hanging out to dry with narrower networks, that did not address balance billing so that patients who knowingly and in many cases unknowingly are seen by non-participating providers are left holding the bag for exorbitant medical bills…WHY DID OBAMACARE DO NOTHING TO ADDRESS THE “tens of billions of dollars a year” in costs from fraud?
Because it would require placing demands, not rewarding but placing demands on providers who failed to tackle the problem and frittered away amounts contributing towards the estimated tens of billions of dollars the FBI acknowledges (who knows how much more) is paid out in fraudulent claims and the primary stakeholder subject to PUNISHMENT provisions under Obamacare is consumers.
Sure, the federal government gave itself $350 million over 10 years to “boost anti-fraud” efforts (ttps://www.stopmedicarefraud.gov/aboutfraud/aca-fraud/) but there is no flurry of dollars paid to insurance companies for discovering fraud and passing those savings onto consumers comparable to Obamacare incentives such as those paid to providers who pursue “value models” cutting what they provide and therefore charge to patients.
And the proof of the ineffectiveness of the 80-20 rule is there too. Insurers quickly discovered work-arounds, so fast that in fact in a one-year period insurers were able to overhaul their accounting so that the $519,313,127 paid out to consumers in 2012 was down to $332,152,474 in 2013 (36 percent). Imagine if there were penalties for failing to tackle health insurance fraud or if there were cash rewards for consumers for finding such fraud, or if consumers had to be refunded money for a failure to have an active and effective fraud investigation program AND if insurers were required to pass those savings onto consumers.
