California insurance firm over billed Medicare $424 million

December 17, 2012

A California health insurance company over billed Medicare $424 million, according a report issued by the U.S. Health and Human Services Inspector General. [California Watch]

PacificCare, now owned by United Health Group, claimed that patients on its Medicare Advantage plan had serious ailments that medical records did not confirm. The inspector general reviewed 100 cases from a 2007 contract between PacifiCare and Medicare and determined that in 45 of the cases diagnostic codes used for billing purposes did not match the corresponding medical records.

In one such case, PacifiCare submitted a diagnostic code for a genetic disorder involving abnormal brain function when records only mentioned a fever and a cough. PacifiCare reported that another patient had prostate cancer when medical records only discussed a shoulder suture removal. And in a third case, PacifiCare reported septicemia, a lethal infection of the bloodstream, despite the patient having knee surgery and no condition relating to a bloodstream infection.

The inspector general determined that Medicare overpaid PacifiCare $224,388 as a result of the 45 cases with incorrect or exaggerated diagnoses and ordered the firm to repay the amount.

PacifiCare billed Medicare for the treatment of 188,000 patients under the same 2007 contract. At the same rate of over payments, the inspector general estimated that PacifiCare over billed Medicare about $424 million.

The insurance firm continues to operate under the same name under the ownership of United Health Group, which objects to the findings in the inspector general’s report. United Health Group issued a statement saying the 100 cases reviewed should not be used to generalize hundreds of other claims.

“The audit does not follow Medicare’s own guidelines, standards or accepted methodology for validating risk-adjustment payments,” the United Health Group statement says.

The inspector general reviewed the UnitedHealth’s response before issuing the report Thursday.

A month prior, the inspector general found that Medicare overpaid nursing homes by about $1.5 billion in 2009 due to claims that patients needed “ultra high” levels of therapy.


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How big? “UnitedHealthcare continues to offer the largest, national provider network on a single platform. Total counts now stand at 684,125 physicians and health care professionals and 5,536 hospitals.” “Expenses”? In 2009, they paid CEO Stephen Helmsley $102 million. Obamacare will require 80% of income to go to healthcare payments, not profit.

I used to do medical billing and let me tell you PACIFIC CARE is one of the worse ones out there. They do not pay claims in the time frame they are suppose to. It is like going up against a great white shark to get them to authorize anything and then to get payment is another ordeal.

the give wrtten authorization and then after surgery say they had not given it. Most insurance companies play this little game of saying that the authorization is “not a guarantee of payment” and things like that.

With Pacific Care it does not shock me to read they up coded the billing on patients. They try so hard not to pay, that if they end up paying they have to recoup the loss somewhere, so why not over bill.

If nobody is in jail, then it’s ok. Ho Hum….back to dressing up my dogs for their “fleas navidog” photo.

Pics or it never happened ;)

The insurance companies have paid a lot for their politicians to do nothing to prevent them from recouping their expenses on the backs of taxpayers, and it ‘s working otherwise Obamacare would have actually had something to prevent this and the politicians would have been made to take part in it as well as Obama not giving Democratic contributor’s companies exemptions.

A number of questions here:

1) 188,000 patients? How big is this company and how many doctors does it have?

2) Is it doctors who are cheating by turning in false reports or the insurance company?

3) Regardless of the answer to the above, aren’t you glad that all of us are paying for this with our tax dollars?

4) Is there ANY incentive in Obamacare not to make this the norm?This fraud is already happening in government health care; just wait til that’s the only show in town.