Public Pension Plans Struggle to Meet Funding Obligations

Low interest rates are one of several factors contributing to higher levels of unfunded pension liabilities at state and county pension plans across the country.

The California Public Employees’ Retirement System (CalPERS), the largest U.S. public pension plan with 1.8 million total members covered by 3,000 employers, reported a 0.6 percent net return on investments for the 12-month period that ended June 30, 2016.

The California State Teachers Retirement system (CalSTRS), which manages retirement funds for California’s 896,000 public school educators from 1,700 school districts, reported a 1.4 percent net return for the 2015-16 fiscal year ending on June 30, 2016.

Both California funds have a target annual return of 7.5 percent. CalPERS and CalSTRS had $62 billion and $74 billion in unfunded liabilities, respectively, as of the 2013 fiscal year, according to the Public Policy Institute of California. CalSTRS now states that it is on track to achieve full funding by the year 2046.

The New York State and Local Retirement System reported an average rate of return of 0.2 percent for the fiscal year on March 31, 2016, compared to its stated goal of 7 percent.

The Oregon Public Employee Retirement System (PERS) reported a 2 percent investment return in 2015, compared to its goal of 7.75 percent, resulting in an increased liability of $3 billion.

A 7.7 percent average rate of return is now the target set by most state and county pension funds across the country, according to a 2015 report by the National Association of State Retirement Administrators. The Center for Retirement Research at Boston College estimates that every 1 percent decrease in investment returns results in a 12 percent increase in liabilities.

The inability of state and municipal pension plans to properly fund current liabilities at the same time that rates of return are falling is causing significant underfunding. The situation is putting pressure on public pension managers and elected officials across the country.

New public pension accounting standards are also bringing more attention to underfunded municipal liabilities. The Government Accounting Standards Board issued GASB Statement No. 67, Financial Reporting for Pension Plans, and No. 68, Accounting and Financial Reporting for Pensions in recent years. The new reporting standards for government-administered pension plans took effect for reporting periods after June 15, 2013 under Statement No. 67, while new employer reporting standards followed one year later under Statement No. 68.

The Pew Charitable Trust reports that as of 2013, states owed almost $1 trillion in unfunded pension benefits as well as $587 billion in unfunded retiree health care liabilities. Looked at another way, Wilshire Consulting estimates that state pension obligations are only 75 percent funded as of 2013, despite that fact that most states strive to maintain an 80 percent funding level.

The State of Illinois alone has $101 billion in unfunded pension liabilities and $56.4 billion in unfunded retiree health care benefits, according to The Pew Charitable Trust. Illinois is listed by the Trust as having the third highest level of debt and unfunded retirement costs as a share of state personal income (after Alaska and Hawaii) as of 2013. In June 2016 Moody’s Investors Service downgraded the credit rating of some of the state’s general obligation bonds to Baa2, down from Baa1, which is two units away from junk bond status.

The City of Chicago is struggling with its own pension challenges. The City’s Municipal Employees’ Annuity and Benefit Fund, which covers 70,000 workers, reported that unfunded pension liabilities more than doubled to $18.6 billion at the end of 2015 from $7.1 billion a year earlier. Moody’s reduced the city’s credit rating to junk bond status in 2015.

Municipalities are responding with a wide range of measures to increase pension funding, reduce benefits, and cut expenses. Representative actions include the following.

  • Chicago implemented a property tax hike in 2015 to better fund the police and fire retirement funds. The mayor also seeks an increase in water and sewer levies as a means to support municipal retirement benefits.
  • Pennsylvania officials are evaluating a range of pension plan changes, including the possible adoption of less expensive 401(k)-style plans.
  • Connecticut now devotes 10% of its budget toward unfunded pension liabilities, which doubled in the past decade.
  • Oregon plans to increase pension funding rates, which is likely to translate into expense reductions such as teacher lay-offs, larger class sizes, and public safety cuts.
  • Detroit’s municipal bankruptcy was settled, in part, with pension cuts of 4.5 percent approved by certain retirees. Benefit reductions were also seen in the areas of cost-of-living adjustments and health care costs.

Pension Funding Litigation a Certainty

As states and municipalities struggle to fund pension obligations in a low interest rate environment, court battles in New Jersey, Illinois, California and Michigan may serve as precedent for similar challenges likely to unfold across the country.

Source by Mark Johnson, Ph.D., J.D.

How Can I Get My Employment Insurance Claim Processed Faster?

How can I get my Employment Insurance Claim processed faster? There are some little tricks that will have your Employment Insurance processed fast and easy, without delay. When first applying for E.I., you will be given an access code, Make sure you complete your reports for the four weeks period leading up to your approval of benefits.  Failure to make your two week reports can cause your Employment Insurance benefits to be delayed, and that is the last thing you want.  When your claim is approved you will have to complete your reports again but this time the money will be in your account in two days.

One way to have your Employment Insurance claim processed faster is to meet with the adjudicator that is working on your E.I. claim. I find this approach to very effective when you left your last position on bad terms. E.I. will contact your employers to find out why you are no longer working there. But if they are unable to get a hold of the appropriate people, they have your side of the story face to face. Nobody wants to deny some on their benefits and this will make it a lot harder.

This Method Is 100% Successful when you quit your job on bad terms. It works great, most people never think about this avenue. But sometimes meeting with the person working on your case can be difficult if you live in a small town and your claim is processed in another city. Take a shot, and do everything you can to meet with the right people.

Source by Liam Gannon

Mesothelioma And Smoking

Mesothelioma is not caused by smoking but can complicate a person’s likelihood of getting the disease.

Mesothelioma is a fatal cancerous disease caused due to exposure to asbestos. This disease is unique as its symptoms appear after years.

The survival rate is much lower in this disease due to the inability of its diagnosis.

The combination of asbestos and smoking can be very dangerous even if it is done many years ago. It can lead to lung cancer or any other lung related diseases.

Though extensive research is performed in this field, there still is no major breakthrough in this field to completely cure the disease.

Fine fiber get deposited in the lungs leading to scar tissue which results in cancer and this is aggravated by smoking. It was found in during 1950s, the Kent brand of cigarettes used asbestos in its filters resulting in some cases of mesothelioma.

The cases of mesothelioma has increases over the last 20 years as its latency period takes about 40 to 50 years but still mesothelioma is considered as a rare form of cancer.

It is found in the number of cases. i.e. about 1 per 1,000,000.

Whereas in the case of smoking, people with a higher level of smoking can contract lung cancer more than mesothelioma and the number of incidents is as much as 1,000 per 1,000,000.

Due to extensive exposure of asbestos in Western countries, the incidence of malignant mesothelioma is increasing to 7 to 40 per 1,000,000 and it has increased to about 15 per 1,000,000 in United States in 2004.

Smoking should be immediately stopped after diagnosis:

A person suffering from mesothelioma should not smoke as the lungs can be further damaged by the side effects of smoking leading to asbestosis. It is not a kind of mesothelioma, but if ignored it might become cancerous. Smoking does not lead to increased cases o but it is debated that it leads to 50% more chances of causing lung cancer.

It is imperative for the patient to stop smoking as soon as the disease is diagnosed as the patient who is smoker can develop comparatively more lung-related complications than those who do not smoke but are were exposed for many years.

In the case of lung cancer, the amount of cigeratte smoked and the time frame matters whereas in the case of mesothelioma, the amount of asbestos inhaled and the time frame matters.

While the ban on asbestos has been implemented, let us hope the same for a ban on smoking as well!

Source by Adia O’Hara

Medical Identity Theft – Deadly Consequences

Of all the ways we are victimized through identity theft, truly the most devastating could be the fraudulent theft of medical benefits. Although the least studied and worst documented form of the crime, this one has far reaching and almost irreversible repercussions. Recent federal and state legislation have provided consumers an extensive array of rights and protections to battle the effects of financial identity theft. In stark contrast, those victimized through the misuse of their “medical identity” are often left with no recourse and face almost insurmountable challenges during their attempt to correct fraudulent medical information.

The real damage in these cases occurs when a victim’s medical record is changed to suit the needs of the thief. Unlike your credit file(s), you do not have the same rights to correct or dispute the medical information in your file. To illustrate the point, let’s refer to the 1996 case against Dr. Richard P. Skodnek of Massachusetts. Dr. Skodnek was convicted of over 130 counts of fraud related to false Medicare and insurance billing. The previously highly respected psychologist had been submitting claims to his patients’ insurance providers for treatments and appointments that did not take place. In some of the cases he also claimed to provide treatment to the siblings of his patients when in fact he had never even met them. All of these fraudulently billed “sessions” and related diagnoses were documented in each victim’s personal, permanent medical history. A judge in the case reviewing the impact on victims wrote;

“The evidence suggests that once the claims were entered they cannot be deleted from the system. The most that can be done is to enter a notation in the computer records to reflect that a particular claim was false”. And – “Moreover, even where a notation is entered to show that the billing record was false, the insurance carrier cannot declare–and the notation will thus not reflect –whether Skodnek’s statements about diagnosis, medications prescribed and/or psychiatric symptoms of the patient were false.”

United States v. Skodnek, 933 F. Supp. 1108,; 1996 U.S. Dist. LEXIS 9788 (D. D. Mass. 1996)

With this statement in mind, remember that your medical information is also used to make other decisions about you besides treatment of illness. Victims have had available benefit totals decreased or used entirely and have also been denied life or medical insurance, security clearances and even employment.

Detecting the theft or misuse is almost as difficult as correcting your information. Some of the ways people have discovered they had been victimized include;

  • receiving someone else’s medical bills at their address
  • collection notices from agencies and attorneys for medical services they never received or from providers they never used
  • notifications from insurance companies, law enforcement or healthcare providers
  • inaccurate information in their medical file (i.e.; different blood type or allergies and illnesses not suffered by the patient)
  • denial of benefits or employment

Although they are potentially time consuming, there are some steps consumers can and should take to detect medical identity theft.

  • Obtain and review a copy of your Medical Information Bureau report. All consumers are entitled to one free copy each year under the Fair and Accurate Credit Reporting Act (FACTA). Included in the report is who has reported information to the MIB, requested your file and also the consumer’s individual insurance application activity. Visit www.mib.com for information and instructions for consumers.
  • Review any “Explanation of Benefits” sent by insurers – even if your balance is $0. Contact your insurer immediately if anything is inaccurate.
  • Review all statements and bills sent by health providers and insurers carefully. Never assume mistakes were accidental and will be corrected. Call and question inaccurate entries with both the provider and your insurer.
  • Annually request complete medical files and an accounting of disclosures from each medical provider you see and your insurer(s). Include hospitals you may have visited over the year for any reason. Review them carefully and immediately dispute errors.

Unlike financial identity theft, monitoring services are not available to alert you when your medical information has been accessed or altered. The detection and correction of this crime will be your responsibility for the foreseeable future. However the best identity theft monitoring and restoration services available to consumers will include valuable assistance if you are victimized by this type of theft. The best advice to consumers is to educate yourself and monitor your information and statements carefully. Lastly, seriously consider a top-rated identity theft service for your family that specifically addresses this crime.

Source by Rick Christiana

Sh! Your Insurance Company May Be Spying on You!

Inside story about auto, workers comp and other accident insurance claims

So here’s the scoop in regard to your auto, workers comp, disability or any policy that includes accident coverage.

Insurance companies, if you do not realize, are not willing to lose money. In fact, the real agenda behind being in business is to make money in the way of profits. Now, because related studies demonstrate the presence of significant insurance fraud – something that amounts to the tune of about $30 million in losses for the industry that is passed on as well as to the customers – insurance providers in general choose to do as much as legally permissible to thwart false claims related to liability.

To that end, the industry invests quite highly in several means that monitor a claimant’s activities so as to verify the accuracy and validity of an injury call. Though the vast majority of those bringing a related claim honestly suffer from the injury that is cited, as a preventive course, anyone is subject to suspect.

After you submit a claim, your insurance company may do one or more of the following:

• Search your social media accounts for any reference to your accident

• Scrutinize your medical records to see if there are any inconsistencies

• Interview witnesses of the accident

• Speak to your employer to hear his take on your work activities and how it relates to your injury

• Hire professional investigators to spy on you and gather any evidence that indicates you are lying

Insurance sources will be on the lookout for any contradictory evidence. For instance, if you say your leg has been broken and investigators check in with your tweet about running in your kids’ school-sponsored picnic race that features you winning the gold star after crossing first in the finish line, you will definitely find yourself in real hot water!

Of course, for the honest claimant, there should be nothing to be afraid of in regard to ongoing insurance inquiries. Nonetheless, it’s important to go by the guidelines listed below:

1. Be as accurate as you can when describing your injuries in the claim, as well as when you describe them to family or friends

2. Don’t post claim info online in full view of public’s eye

3. Follow doctor’s instructions regarding limited physical activity

For more about auto injury and workers comp claims, contact a qualified and experienced independent insurance agent that deals with many of the leading underwriters in the industry.

Source by M Wyzanski

Asbestos in Your Digestive System

When most people picture diseases related to asbestos, they think of mesothelioma. It is true that mesothelioma is directly linked to exposure to asbestos, but this is not the only disorder that can arise as a result of contact with asbestos. Additionally, lungs are not the only areas of the body that can suffer from asbestos exposure. In fact, asbestos can also cause cancer in the digestive system.

Although asbestos is now mostly banned and otherwise strictly controlled, it was once a very popular material for many different industries, such as construction, automotive, and shipping. Asbestos is a silicate mineral that can insulate against heat, flame, chemicals, and electricity. Also, this material is strong and flexible, which makes it easy to be added to everything from ceiling tiles to brake pads to fire doors.

Normally, asbestos is not harmful when it is combined with another strong material. However, as an asbestos-containing item ages, it can degrade. This allows the asbestos to escape in microscopic particles. If you inhale these fibers, they can go into your lungs, or they can get trapped in your mouth.

From here, swallowing your saliva can then transfer the asbestos to your digestive system. Additionally, if airborne asbestos settles on your food, you can consume the particles that way. Lastly, some water mains were constructed with asbestos-laden cement, which can break down and release asbestos into the water supply. You can drink the water and ingest the fibers.

Our bodies do not have the ability to break down the asbestos fibers once they are lodged in our tissue. Thus, the trapped fibers can grow into tumors. There are several different types of cancer that have been linked to asbestos in the digestive system, including:

  • Gastrointestinal
  • Colorectal
  • Kidney
  • Throat
  • Esophageal

Even a single moment of asbestos exposure can lead to devastating consequences. If you believe that you have been exposed to asbestos, you may want more information to learn more about your risks. Please visit the Asbestos Help Center today for more information.

Source by James Witherspoon

Grow Revenues in Chiropractic Clinic With Point of Service Sales of Retail Products

In 2006, two out of three chiropractors increased billings (67%), while almost ninety percent (88.3%) of chiropractors sold retail products to patients. At an average $28.5 collections per patient visit (PVA), retail product sales to patients remains a major revenue source. But for junior practitioners with a humble patient growth record, point of service sales is the fastest way to increase practice revenue.

An added benefit of such sales is improved patient relationship. By offering your patients quality products that enrich their lives outside of your office, you demonstrate your care. Your patients are reminded of you – and of your care about them – every time they use the products you sell them. Better patient loyalty means lower attrition, frequent referrals and, eventually, improved profits.

Stick to familiar products. Offer products you use during your treatments. Offer items like topical analgesics, hot and cold packs, orthopedic pillows and supports, water-based pillows, herbal packs, massage tools, lotions, oils, butters, scrubs, aromatherapy, etc., which can be used in your office to benefit your patients daily.

Maintain exclusivity. Choose products not available in retail stores. Patients feel special if you offer products they can not find in mass retail markets.

Display. Set up retail displays in both waiting room area and the treatment room. Make sure the patients can feel, touch, sample, read about the benefits of the products, and ask you questions, giving you an opportunity to talk about their benefits.

Manage accounting. Best billing systems manage both healthcare claims and point of service sales records uniformly, without imposing extra complexities on practice management. The challenge is to process healthcare claims with insurance companies while leaving point of sales records aside and still produce correct sales and balance reports for each patient.

Source by Yuval Lirov

Fire Claims Process

The fire claims process is considered the time that the policy owner notifies their insurance company of the fire until the claim process is finished and ends in a settlement for the policy owner. To get to the end point there are several steps involved.

Review your policy

At all times you should know where to look for and find your insurance policy. It should be in a safe fireproof lock box or safety deposit box rented from the bank. When there is a fire you should get your insurance policy out and review it to determine what type of coverage you have and how much it is for, what is covered and what is excluded. This information will help you know how you should file your claim and if there are any deadlines to file your claim. Most of the information that you will need can generally be found on the declaration page. This is usually found at the beginning of your insurance policy. If, for some reason or other, you cannot find your insurance policy or do not understand what is covered and how to file a claim contact your insurance company.

Contacting your insurance company

As soon as you review your policy, or even before if you want, you should contact your insurance company to notify them of the fire and what type of loss you have suffered. Some insurance companies may require that you contact them as soon as the loss occurs while others may give you a couple of days. This information will also be in your insurance policy. With some insurance policies there are often provisions that will provide you with money for temporary housing if your home was destroyed by fire, which is another reason you should contact them as soon as possible. You may have to submit written notification instead of calling.

Information needed by insurance company

When you contact your insurance company they will tell you what you need to submit in order to start the fire claims process. This will generally consist of a statement from you telling what happened and what the damage is. If they need more information or documentation it is your responsibility to provide it as long as what they request is reasonable. Make sure that in all of your documentation that you are thorough because you will not be reimbursed for anything that is not documented.

Payment process

How you will be paid for your loss will depend on the type of fire claims you submitted and what the loss was. If it is a small loss the insurance company may just write a check but if it is to do repairs or rebuilding they may disburse the payments to the one doing the work.

Source by Lora Davis

Can Lung Cancer Be Prevented?

Lung cancer is the most fatal form of cancer in the US, and other developed countries, today. And the fact is, that most of the cancer treatments that work well on other forms of cancer often don’t work well on lung cancer. Add to that the fact that lung cancer is often not diagnosed until it is far advanced, and it’s easy to understand why this disease is so often fatal.

So, preventing lung cancer is even more important than preventing many other types of cancer simply because the prognosis is often so poor. And, for most victims of this disease, it is entirely preventable – simply by not smoking. Eight out of ten people diagnosed with lung cancer each year are smokers.

Six out of ten people who are diagnosed with lung cancer will die within one year. Between seven and eight will die within two years. Treatments are improving, and today there are some long term lung cancer survivors. But, as we focus on better treatments, we cannot lose focus on prevention.

Of course the simplest way to prevent lung cancer is not to smoke. But, there are some other things you can do to help reduce your risk of lung cancer, whether or not you smoke.

The first is to eat a healthy diet, rich in fruits and vegetables. Some studies have shown that people who eat a diet lacking in fruits and vegetables have a higher risk of lung cancer than those whose diet offers a wide variety of such foods.

In addition to not smoking, it’s important to stay away from others who smoke. Secondhand smoke is just as dangerous as smoking yourself. The American Cancer Society reports that non-smoking spouses of smokers are 30% more likely to get lung cancer than spouses of non-smokers. In addition, exposure to asbestos, arsenic and radon increase your risk of lung cancer.

Add Green Tea to Your Diet

Another little known trick for helping protect your body from many types of disease, including many forms of cancer, is drinking green tea. Green tea has been shown in many studies to be effective at protecting health and preventing disease. This is because green tea is filled with anti-oxidants – some of the most powerful available.

Anti-oxidants are very effective at combating free radicals that are created in our bodies as we process food. The free radicals produced by our bodies damage our cells and our DNA, and eventually lead to disease if we don’t combat them. Anti-oxidants, however, combat these free radicals before they can cause damage. If we’re getting our fair share of anti-oxidants each day, we’re keeping these free radicals under control.

Above I mentioned that scientists believe that a diet rich in fruits and vegetables helps prevent lung cancer. This is also likely due to the fact that fresh fruits and vegetables are good anti-oxidant sources. Some vegetables and fruits are better than others, so for optimum benefit, be sure to include some of the most powerful in your diet on a regular basis.

The best food sources of anti-oxidants include:

o Artichokes

o Asparagus

o Red Beans

o Blueberries

o Pomegranates

o Dark Chocolate

o Tomatoes

And, green tea. One of the most important anti-oxidants is EGCG, which is found in abundance in the Camilla sinensis (tea tree) plant. Green tea is the best form of this anti-oxidant because it’s not fermented during processing. Black tea is fermented, which changes some of its anti-oxidant compounds. Black tea is still healthy, but your best anti-oxidant source is green tea.

One study recently reported by the UK Tea Council shines light on green tea’s ability to prevent lung cancer. In particular, this study showed that green tea appears to have two major functions that prevent cancer.

Green tea appears to cause apoptosis of abnormal cells. Apoptosis is the orderly process of cell death. Cell death due to apoptosis is good, because it is a process of killing off damaged or unneeded cells. Green tea seems to help the body rid itself of potentially harmful cells by inducing the process of apoptosis.

Green tea also seems to help prevent lung cancer by inhibiting the growth of the abnormal lung cells. So, green tea keeps the cells from growing and spreading until the apoptosis can kills the cells off. These two powers help to rid the body of abnormal cells before they can replicate and cause a problem.

Of course, more research is needed to pinpoint exactly how green tea works, and how we can use it best to prevent lung cancer and many other diseases. However, in the mean time, there’s no reason not to make green tea part of your daily life.

Green tea is an absolutely safe beverage to consume. It has no side effects, and even those who are caffeine sensitive can usually tolerate green tea quite well, because its caffeine content is very low compared to coffee and sodas. So, do something good for yourself – drink some green tea!

Source by Jon Stout

Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ‘sleight-of-hand’ precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

– The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

– The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

– DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

– REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…

– REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

– PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

– PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

Source by Daniel J Osborne