Something didn't look right. Maxim Healthcare nurses were showing up at Richard West's house according to one schedule. But Maxim was billing the government according to another.
West complained to the state: The company was charging for hundreds of hours of work it never did. Officials blew him off, he said. He alerted Medicaid, the state and federal program that paid for his care. Nothing happened.
He told a social worker. She expressed concern, but did nothing. But West, a Vietnam vet with muscular dystrophy, kept pushing and pushing, building a giant, accusatory snowball that landed last week — eight years later — on Maxim's Columbia headquarters.
Maxim has signed a criminal and civil settlement related to allegations that it schemed to rip off $61 million from state and federal governments, law enforcement authorities said last week. The company is paying $150 million in penalties and recompense. Eight former Maxim employees so far have pleaded guilty to felony charges in several states.
If Washington is as serious about fighting medical fraud as it pretends to be, it will recruit an army of Richard Wests to burn off leeches like Maxim. Nobody is in a better position to see fraud than patients, who can check the care they receive against what's on the invoice.
Now that West has shown that patients can get rich in the bargain, there's plenty of incentive. Not that his motivation was his $14.8 million share of the settlement. Anger was. He didn't even know about such whistleblower rewards at first.
"Somebody decided to make a profit on my disability," West said in a telephone interview. "This is your country. You see fraud, you should turn them in. That is part of being an American."
Whistleblower rewards under the federal False Claims Act have been around since the Civil War. The recent caseload has been dominated by allegations of Medicare and Medicaid fraud, which costs taxpayers billions of dollars a year.
In almost every instance, the person who alerts law enforcement is a corporate insider, not a patient. West's information in the Maxim case was so compelling, however, that the government credited him as the "original source," with independent and direct knowledge of the fraud.
He kept spreadsheets on the gaping discrepancy between the hours Maxim nurses spent in his home north of Atlantic City, N.J., and the hours Maxim billed Medicaid. Eventually he documented more than 700 hours of bogus charges, according to the New Jersey attorney general.
After a couple months of detective work, West got in touch with Baltimore lawyer Robin Page West (no relation), who specializes in whistleblower lawsuits. Together they built a case, filed it under court seal in 2004 and turned it over to law enforcement. And waited.
West, 63, speaks precisely but with difficulty, in a high-toned voice. He says he commanded an Army track vehicle with 40 mm guns in Vietnam in 1968 and 1969 — the deadliest years of the war there. Yet biding his time while investigators built their file, he said, "was the hardest thing I've ever done."
The Cockroach Catcher was privileged to be having dinner with his good friend.
He covered the bottle when he served his favourite red wine.
"See what you think."
"Fully of blackberry and long with good tannin that has softened."
"1996 and the tannin will keep it going for another 5 years."
"Of all the recent great wines that you have served and that included the second wines of Lafite and Margaux, this is the most impressive. Just like our NHS!"
"But now you have one of the most impressive guys running it."
"Selling it, you mean!"
"I did not want to upset you."
"So you know about Simon Stevens. Not just wines then."
"You need to know that Britain is responsible for producing all the great doctors in the old commonwealth. My cardiologist was trained there. Look at Singapore, Australia & New Zealand, generations of doctors were all trained in the UK and in turn the next generations.
Why do you think that UnitedHealth paid so much to get one of the top UK guys to add a new perspective?
UnitedHealth is based in Minnesota, home of the famous Mayo Clinic and Simon Stevens is married to an American and they have school age children. As you well know, it is not easy for Americans to adjust to British life."
UnitedHealth followed up on June 30 with another report for lawmakers pinpointing $332 billion in savings through better use of technology and administrative simplification. If enacted, those changes would potentially benefit UnitedHealth's Ingenix data-crunching unit. Ingenix, with annual revenue of $1.6 billion, is poised to establish a national digital clearinghouse to ensure the accuracy of medical payments and provide a centralized service for checking the credentials of physicians.
Stevens, an Oxford-educated executive vice-president at UnitedHealth, once served as an adviser to former British Prime Minister Tony Blair. In that capacity, Stevens tried to fine-tune the U.K.'s nationally run health system. Today he tells lawmakers that the U.S. need not follow Britain's example. Concessions already offered by the U.S. insurance industry—such as accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues. "We don't think reform should come crashing down because of [resistance to] a public plan," Stevens says. Many congressional Democrats have come to the same conclusion.
UnitedHealth has traveled an unlikely path to becoming a Washington powerhouse. Its last chairman and chief executive, William W. McGuire, cultivated a corporate profile as an industry insurgent little concerned with goings-on in the capital. From its Minnetonka(Minn.) headquarters, the company grew swiftly by acquisition. McGuire absorbed both rival carriers and companies that analyze data and write software. Diversification turned UnitedHealth into the largest U.S. health insurer in terms of revenue. In 2008 it reported operating profit of $5.3 billion on revenue of $81.2 billion. It employs more than 75,000 people.
Stevens argues that while UnitedHealth will likely benefit financially from health reform, the company will also aid the cause of reducing costs. He cites what he says is its record of "bending the cost curve" for major employers.
During a media presentation in May in Washington, Stevens said medical costs incurred by UnitedHealth's corporate clients were rising only 4% annually, less than the industry average of 6% to 8%. But that claim seemed to conflict with statements company executives made just a month earlier during a conference call with investors. On that quarterly earnings call, UnitedHealth CEO Hemsley conceded that medical costs on commercial plans would increase 8% this year.
Asked about the discrepancy, Stevens says the lower figure he is using in Washington represents the experience of a subset of employer clients who fully deployed UnitedHealth's cost-saving techniques, including oversight of the chronically ill. "These employers stuck at it for several years," he says. "We are putting forward positive ideas based on our experience of what works."
"So there is not reason for him to leave UnitedHealth! They love him. The best of British & of Oxford!"
"Perhaps he has not left UnitedHealth!"
"So perhaps a sort of UnitedNHS then!"
"Well despite what people say about Obamacare, even Stevens concede that:
.....the U.S. insurance industry—accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues.
"NHS as such was the most serious competitor to the Health Insurance Industry. It is serious because there is not even any co-pay!"
"And quality is the same as the actual specialist doctor on either side are the same."
"Only the coffee is better!"
"Whatever Stevens plan to do is not something most of us can begin to guess but my suspicion is that it would not be to anyone's liking..."
"Except the Health Insurance Industry."
"So, he will not follow the US example of insurance industry accepting all applicants, regardless of age or medical history."
"You see, UnitedHealth has decided to leave California because of that."
"If Insurers need to cover everything in England, they would think twice and most likely do aCalifornia thing."
"And Stevens can go back to America then!"
"So what is the wine?"
"Big Sail Boat!"
"Big Sail Boat?"
That the logo might have helped to sell a wine is unthinkable if the wine is no good. Ch. Beychevellewas fortunate enough to have a boat on its label and the Chinese just embrace it now that Lynch Bages hit the roof and there are too many fake 1982 Lafites around.
When my friend stock up on his Beychevelle, it was he told me, just a third of the price right now.
I recently learned that this month a class-action lawsuit has been filed against California United Behavioral Health (UBH), along with United Healthcare Insurance Company and US Behavioral Plan, alleging these companies improperly denied coverage for mental health care.
According to the class action lawsuit, United Behavioral Health violated California’s Mental Health Parity Act, which requires insurers to provide treatment for mental-health diagnosis according to “the same terms and conditions” applied to medical conditions. Specifically, the insurer is accused of denying and improperly limiting mental health coverage by conducting concurrent and prospective reviews of routine outpatient mental health treatments when no such reviews are conducted for routine outpatient treatments for other medical conditions.
Pomerantz Law Firm has filed a Class Action Against UnitedHealth Group, Inc. for Violations of Federal and State Mental Health Parity Laws - UNH
NEW YORK, March 12, 2013 (GLOBENEWSWIRE) Pomerantz Grossman Hufford Dahlstrom & Gross LLP has filed a class action lawsuit against UnitedHealth Group Inc. (“UnitedHealth” or the “Company”)(NYSE: UNH) and various subsidiaries, including United Behavioral Health. The class action was filed in the U.S. District Court, Southern District of New York, and docketed under 13 CV 1599, alleging violations of federal and state mental health parity laws and other related statutes. The action has been brought on behalf of three beneficiaries who are insured by health care plans issued or administered by United and whose coverage for mental health claims has been denied or curtailed. These plaintiffs seek to represent a nationwide class of similarly situated subscribers. In addition, the action was filed on behalf of the New York State Psychiatric Association, Inc. (“NYSPA”), a division of the American Psychiatric Association, seeking injunctive relief in a representational capacity on behalf of its members and their patients.
The health insurer violated state law nearly 1 million times from 2006 to 2008 after it was bought by UnitedHealth Group, the Department of Insurance says. The fine, if there is one, is likely to be much less than the maximum allowed.'
UNITED HEALTHCARE INSURANCE AGREES TO PAY U.S. $3.5 MILLION TO SETTLE FRAUD CHARGES
WASHINGTON, D.C. - United Healthcare Insurance Company has agreed to pay the United States $3.5 million to settle allegations that the company defrauded the Medicare program, the Justice Department announced today.
The government alleges that beginning in or about 1996 and continuing through 2000, United Healthcare's telephone response unit knowingly mishandled certain phone inquiries received from Medicare beneficiaries and providers and then falsely reported its performance information to the Centers for Medicare and Medicaid Services (CMS) concerning the company's handling of those calls. CMS is the federal agency charged with administering the Medicare program.
From October 2, 1995 to October 1, 2000, United Healthcare acted under contract with CMS as a Durable Medical Equipment Regional Carrier. Under that contract, United Healthcare processed Medicare Part B claims for durable medical equipment submitted to it by Medicare beneficiaries, physicians, and other health care providers and suppliers located in the northeastern United States.
"This settlement demonstrates our continuing commitment to pursue vigorously allegations of fraud and abuse in Medicare," said Peter Keisler, Assistant Attorney General for the Department's Civil Division. "Medicare contractors, along with other health care providers, can and will be held accountable for their billing practices. This settlement demonstrates our unwavering pursuit of fraud and abuse."
The allegations of improper conduct were brought to the attention of the government by a former United Healthcare employee, who filed suit under seal in November 2001 under the qui tam or whistleblower provisions of the federal False Claims Act. The United States recently intervened in the whistleblower suit.
As a result of today’s settlement, the whistleblower will receive $647,500 of the settlement amount. United Healthcare did not admit any of the allegations in the complaint in connection with the settlement. Under the False Claims Act, private citizens can bring suit on behalf of the government and share in any awards that are obtained through that legal action.
“The pharmaceutical giant Pfizer agreed to pay $2.3 billion to settle civil and criminal allegations that it had illegally marketed its painkiller Bextra, which has been withdrawn.”
“The government charged that executives and sales representatives throughout Pfizer’s ranks planned and executed schemes to illegally market not only Bextra but also Geodon, an antipsychotic; Zyvox, an antibiotic; and Lyrica, which treats nerve pain. While the government said the fine was a record sum, the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales.”
My main interest is in the antipsychotic Geodon (Ziprasidone )
“Geodon is FDA-approved only to treat patients ages 18-65 diagnosed withschizophrenia or acute manic or mixed episodes associated with bipolar disorder. However, according to thewhistleblowersuit unsealed today, Pfizer illegally promoted the sale and use of Geodon for a variety of off-label conditions,
including depression, bipolar maintenance, mood disorder, anxiety, aggression, dementia, attention deficit hyperactivity disorder, obsessive compulsive disorder, autism, posttraumatic stress disorder, and for pediatric, adolescent and geriatric patients.”
That sounds like every known condition!!!
"Pfizer targeted pediatrics and adolescents to expand off-label use and maintained on its payroll an army of more than 250 child psychiatrists nationwide." Kenney stated that, "Pfizer regularly paid generous speaking fees to these child psychiatrists to give what were basically promotional lectures about the benefits of Geodon to their peers, who were naturally also child psychiatrists, despite the fact the drug is not FDA-approved or medically indicated to treat children at all."
"……the purpose and intent of paying so many child psychiatrists is clear-- to gain a foothold within the fastest growing market for antipsychotics --children. The practice of expansive off-label use is dangerous, particularly in children because the drug has not been evaluated for its safety for the unique physiological make up of children."
"……less than 5% of the United States population is diagnosed with schizophrenia or bipolar disorder, yet in 2008 Geodon surpassed the blockbuster benchmark of $1 billion in sales."
"……after drug makers obtain initial FDA approval for a specific use, they often don't bother with expensive testing that would allow them to request a label extension for other uses. They just market the drug off-label."
"……among Geodon's most dangerous side effects is its potential to affect the heart's rhythm, a condition known as QT prolongation, which increases the risk of sudden cardiac death."
Antibiotic as well?
As part of the overall settlement, Pfizer agreed to pay $100 million to resolve allegations that it engaged in the marketing of Zyvox for a variety of off-label conditions beyond the methicillin-resistent Staphylococcus aureus ("MRSA") infections for which Zyvox was FDA-approved.
“Authorities called Pfizer a repeat offender, noting it is the company's fourth such settlement of government charges in the last decade. The allegations surround the marketing of 13 different drugs, including big sellers such as Viagra, Zoloft, and Lipitor.”
I was wondering why they could be so blatant:
“In an unusual twist, the head of the Justice Department, Attorney General Eric Holder, did not participate in the record settlement, because he had represented Pfizer on these issues while in private practice.”
What other corporations did he represent?
“Eric Holder, has a net worth of $5.7 million and lobbied on behalf of three companies in the past five years, according to a questionnaire filed by Holder with the Senate Judiciary Committee.
“In the year before Obama appointed him Attorney General, he made more than $2.1 million as a partner at Covington & Burling, a prominent Washington law firm. The money is unsurprising given his high-profile client list, which includes companies like UBS Financial Services, Merck & Co., and Hewlett-Packard. He was also paid to sit on the boards of MCI and Eastman Kodak Company.”