The Hill had an article on the False Claims Act.  The FCA authorizes private individuals to sue anyone they think is defrauding the federal government. Individuals filed more than 4,700 FCA actions between 2009 and June 2016. The Act provides for treble damages. The spoils are divided among the person alleging the fraud, his attorneys, and the federal government. In 2014, the Department of Justice reported that FCA “recoveries” totaled $5.79 billion. Health care lawsuits accounted for $2.3 billion of that.

The federal government must investigate the claims in every FCA case. The initial investigation is done under seal. Defendants may be investigated for years, but not know about it until their business documents are subpoenaed. The individual alleging fraud can proceed with a case even if the government decides against it.

Increasingly sophisticated groups of attorneys choose to continue. They sue any entity that receives federal payments, claiming that the failure to comply with administrative standards constitutes fraud. At the time the act was passed, the goal was to prosecute fraud cases in which a contractor billed the United States for nonexistent or worthless goods or services.


McKnight’s reported that Aggeus Healthcare CEO James Sayadzal pleaded guilty last year to a conspiracy charge and sentenced in federal court to 366 days in prison and ordered to repay $1.77 million to Medicare.  He was one of three company officers and six doctors who defrauded Medicare related to podiatry services provided to residents of nursing homes and long-term care facilities.

Prosecutors say they carried out a broad scheme from 2009-2015 by creating an electronic medical billing system that would lead Medicare to pay for procedures that weren’t performed or wouldn’t have been covered.  Nursing homes were told that Aggeus podiatrists would treat every resident for no cost to the facility. Some Aggeus doctors then performed unnecessary procedures or billed for procedures that weren’t performed, at Gray’s urging, charging documents say.

 Aggeus owner Yev Gray was sentenced Aug. 15 to 7½ years in prison and ordered to repay $6.97 million on charges of conspiracy and making a false statement relating to health care.

Gray’s wife, Natalie Gray was sentenced in February to 366 days in prison on the conspiracy charge and ordered to repay nearly $1 million. Natalie Gray was former director of corporate and legal affairs for the company.

Aggeus once had offices in 16 states and provided podiatry and other services to thousands of patients.  Podiatrists and nursing homes had complained about inaccurate medical notes or potential fraud.

Politico had an interesting article on the history of Medicaid and how Republicans choose to sabotage it.

In May 1965, Lyndon Johnson signed Medicaid into law–an afterthought tacked onto the administration’s Medicare bill, and one that LBJ scarcely mentioned when he signed both measures into law. Medicaid’s roots were humble, its ambitions modest. As originally conceived, the program provided health insurance to poor children, poor pregnant women and some qualifying parents. In its first year, its budget was less than $1 billion—about $7.7 billion in today’s dollars.  Medicare and Medicaid were quintessential Great Society programs: limited in ambition in scope and designed to help groups of citizens who could not, by virtue of their age or condition, capture the advantages of prosperity.

Over 50 years, successive Congresses and presidential administrations vastly expanded the program’s scope to cover 80 million people, or almost one-quarter of the populationIts budget last year was $378 billion. Medicaid enjoyed broad backing from Republican leaders.  The Social Security Amendments of 1965—the official name of the bill that established both programs—passed Congress with bipartisan support. In the House, 65 Republicans supported the legislation; 73 GOP members opposed it. In the Senate, Republicans voted 13 to 14 in favor of the bill.

With strong bipartisan support, Nixon extended the program to include disabled adults who qualified for Supplementary Security Income and allowed states to care for those in need of psychiatric care or suffering mental disabilities.

With overwhelming bipartisan support in Congress, Reagan expanded Medicaid by sharply raising the income eligibility level for women and children, created new categories of mandatory or optional coverage, and made it easier for people who lost eligibility because of rising incomes to remain in the program during a transition period.

Republicans didn’t set their sights on Medicaid until the mid-1990s, when Newt Gingrich’s conservative revolution turned the party’s caucus to the hard right.

Now, Republicans have proposed cuts to Medicaid which will leave many millions of poor people uninsured.  For 50 years, Medicaid proved a highly elastic Band-Aid for many of America’s economic wounds.  Over two-thirds of its spending benefits children, the elderly, or the blind and disabled. It covers costs for 64 percent of seniors in nursing homes and almost half of all births. It keeps afloat hundreds of rural hospitals, whose clients are disproportionately poor and elderly.  Its desecration will leave us in an unfamiliar and dangerous place.

TrumpCare isn’t an attempt to insure more people—or the same number of people—with greater efficiency or better outcomes. It throws people off insurance to pay for tax cuts benefiting the wealthiest Americans, as Republican skeptics like Maine Sen. Susan Collins have noted.

You and I have been dreaming of this since I have been around, since you and I were drinking at a keg,” House Speaker Paul Ryan told Rich Lowry, editor of National Review. The GOP’s full metamorphosis from the Party of Ronald Reagan to the Party of Ayn Rand is complete.

Some of its leaders can’t even get their heads around the idea of insurance—the means by which people mitigate risk, together. In the year 2017, GOP members of Congress honestly wonder aloud why men should be compelled to buy into plans that cover prenatal services. Shared risk and shared reward: It’s a concept so simple—so fundamental to living in a society—that they teach it in preschool. It’s why women who have children pay into insurance plans that also benefit men who develop testicular cancer. But today’s Republican Party has grown radically anti-social in outlook.

Medicaid was designed, and by increments expanded, to help certain disadvantaged groups: struggling single parents and their children, disabled workers, impoverished older people not yet eligible for Medicare, the underemployed, the working poor. But 50 years ago, no one expected the number of people in these categories to total one-quarter of the nation. It is a testament to the program’s elasticity that it has been able to paper over the inequities of the modern American economy for so long.

The Miami Herald reported the criminal charges of bribery against Bertha Blanco, a Florida health care administrator in exchange for helping a nursing home owner accused of orchestrating a $1 billion Medicare and Medicaid fraud scheme keep his license.  The wide-ranging investigation that federal authorities are calling the nation’s biggest health fraud case.

Blanco made about $31,300 a year overseeing inspections at nursing facilities owned by Philip Esformes, a wealthy businessman who owns dozens of Miami-Dade nursing facilities as well as homes in Miami, Los Angeles and Chicago.

A criminal complaint filed against Blanco accused her of taking tens of thousands of dollars in cash in exchange for tipping Esformes off about violations so he could address them before state inspections.  Blanco’s aid allowed Esformes to keep his license active and continue billing the federal government for questionable patient services.

Federal authorities say Blanco took the bribes and provided patient and inspection records to intermediaries, who delivered the information to Esformes.  Two of those intermediaries, brothers Gabriel and Guillermo Delgado, have made plea deals and are expected to testify against Esformes. The brothers helped investigators get to Esformes by videotaping a cash transaction that prosecutors said was meant to go for bribes.

Esformes is accused of using his 20 nursing facilities to file false Medicare and Medicaid claims for services that were not necessary for 14,000 patients.

Prosecutors said his health care network and other co-conspirators billed $1 billion for fraudulent services between 2009 and 2016.

CNN Money reported the great news for Ohio residents.  Health insurers in Ohio have agreed to sell Obamacare policies in 19 of the 20 counties that had no options for 2018, the state Department of Insurance said.  Roughly 11,000 Ohio residents in these counties currently purchase coverage on the exchange.

“The exchange markets are proving to be more resilient than many would have expected,” said Cynthia Cox, an associate director at the Kaiser Family Foundation. “Premium subsidies protect consumers from paying higher prices and may also make it possible for insurers to stay in counties that are otherwise unattractive.”

Trump is threatening to end insurance subsidies for low income people which will destabilize the market and prompt insurers to exit.  Hopefully, Trump will not intentionally sabotage the market.

Insurers have until late September to commit to participating on the exchanges for next year. That’s when they sign contracts with the federal government.

The Advocate reported the prison sentence for a mother-son team that defrauded Medicare for bogus psychological services for nursing home patients in Louisiana and three other states.  Prosecutors say Medicare paid out more than $13 million under the swindle.  A jury convicted psychologist Rodney Hesson and his mother, Gertrude Parker, each on charges of conspiracy to commit health care fraud and conspiracy to make false statements.

Hesson was sentenced to 15 years in prison and must pay back $13.8 million, and Parker to seven years and restitution of $7.3 million.  Hesson and Parker ran the fraud scheme through two companies: Nursing Home Psychological Services and Psychological Care Services.

The firms contracted with nursing homes in Louisiana, Alabama, Florida and Mississippi. Prosecutors argued at trial that the firms billed taxpayers thousands of times for psychological testing that the patients didn’t need and often never received.

Court records show that two other defendants in the case pleaded guilty last fall.

John Teal, a clinical psychologist, pleaded guilty to a conspiracy charge and was sentenced to two years in prison. Teal admitted to administering tests to nursing home patients who were “either non-responsive or were otherwise unable to meaningfully participate.”

Beverly Stubblefield pleaded guilty to a health fraud conspiracy count and received a 30-year sentence. She admitted she supervised five clinical psychologists and filed false documents.

The Des Moines Register had an editorial about the lack of federal oversight for nursing homes.  “The nation’s worst nursing homes have never received enough oversight, and the problem is getting worse.”

In 1998, federal regulators attempted to crack down on homes that had an established pattern of injuring and, in some cases, killing elderly residents, by creating a list of “special-focus facilities.” Nursing homes that wound up on the list were subjected to increased inspections and penalties.

However, fundamental problems with the way CMS implemented the program arose including refusing to share the list with the media or the public. CMS eventually began publishing the list each time it was updated, but only after The Des Moines Register reported on the secrecy and then-Sens. Tom Harkin and Hillary Clinton sponsored legislation to force disclosure.

The designation, as reported by Kaiser Health News in collaboration with the New York Times, have more serious problems with the way the list is compiled. The number of nursing homes that are designated special-focus facilities at any given time has dropped by nearly half in the past five years — and that’s not because care is improving. Rather, it’s because of federal budget cuts; the program’s $2.6 million budget allows only 88 nursing homes to receive the designation, even though regulators identified 435 as warranting the extra level of oversight.

“Kaiser’s research also shows that many special-focus facilities never clean up their act. More than a third of the nursing facilities that successfully graduated from the list before 2014, theoretically because they improved their care, still hold the lowest possible Medicare rating for health and safety: one star on a five-star scale. And of the 528 existing nursing homes that graduated from the list before 2014, slightly more than half subsequently harmed patients or put patients in serious jeopardy.”

“Taxpayers fund Medicaid and Medicare, which means they’re the ones providing the money that keeps these repeat offenders in business. When homes continue to provide poor care or rack up unpaid fines, CMS needs to act quickly in permanently shutting off the flow of taxpayer money.”

Nursing home administrators from around New Hampshire met with U.S. Sen. Jeanne Shaheen, D-N.H., about the impact on New Hampshire’s elderly if Congress passes TrumpCare.  The providers said they will suffer by passage of “Trumpcare.”

Brendan Williams, president and CEO of the New Hampshire Health Care Association, estimated each of the Granite State’s 76 nursing centers would lose $1.01 million under the proposal. He called the bill “absolutely inhumane.”  “It’s as dark a time for long-term care as I have ever seen it,” he said. “This would be a wrecking ball for New Hampshire’s fragile long-term care system.”

The administrators predicted passage would result in nursing home closures and facilities refusing to take Medicaid patients. Thomas Blonski, Catholic Charities’ CEO and president, said  “I can think of no better way to characterize the incredible extreme that this Medicaid funding crisis has reached than to that, in effect, we’re now providing charity to the state itself,” Blonski said.

NPR had a great explanation of Medicaid enrollment and expenditures.  The article explains that Medicaid is for the old, poor, and disabled, and the cost is reasonable.

Medicaid costs less than 10 percent of the federal budget.  Federal spending on Medicaid in 2015 was about $350 billion, almost one-tenth of the $3.7 trillion federal budget. That money is supplemented by the states, so total spending on Medicaid services was $545 billion that year. Those numbers have been increasing as health costs rise and the number of people who are eligible for the program expands.  By contrast, we spend over 50 percent on defense spending.

Medicaid pays for most nursing home care.  Medicaid pays the costs for about 62 percent of seniors who are living in nursing homes. Inpatient nursing care is some of the priciest health care out there, so even though seniors accounted for only 9 percent of Medicaid beneficiaries in 2014, they used 21 percent of Medicaid dollars, according to the Kaiser Family Foundation.

One third of Medicaid’s budget pays for disabled people.  Medicaid spends almost $200 billion a year caring for people with physical and intellectual disabilities. even though, according to the Center for Budget and Policy Priorities, only about 13 percent of those enrolled in Medicaid are disabled.

Medicaid pays for over half of all births.  Medicaid was established in 1965 as a program to help poor single parents on welfare, along with their children. Two decades after that, the federal government required states to cover poor women who were pregnant for the first time. And in the early 1990s, Congress expanded coverage for pregnant women further to ensure that all pregnant women and mothers of children under age 6 with incomes up to 133 percent of poverty — or $21,599 for a family of two — are covered. According to the Kaiser Family Foundation, about half of all births are now paid for by Medicaid, ranging from 72 percent in New Mexico in 2015 to 27 percent in New Hampshire.