A Medicaid contractor admits to spying on families and officials. The scandal raises urgent questions about the privatization of public health programs.
I completely agree with your statement at the end. The circumstances are salacious, but it is the result of Profit over Patient mentality in for-profit-run healthcare insurance and services for our most vulnerable (Medicare and Medicaid)
It's like cockroaches. If you catch one, you know there are thousands more behind the walls. If anyone wonders why so many people metaphorically high-fived the accused murderer of United Healthcare's CEO, look no further than this slimy example of healthcare privateering. Original Medicare for everyone! Thank goodness I have lived long enough to have original Medicare. I will not ever choose Medicare Advantage. I resent my tax dollars yet again fattening private profits (Medicare Advantage) while siphoning off money that could be directed toward actual healthcare. Raise taxes on the 1 percent and neither Medicare nor Social Security would have funding problems!
Yet another reason private insurers need to stay out of our government health care. Medicare (dis)Advantage also. We need one health plan to cover all of us!
Why is anyone surprised? ALL insurance companies surveil and/or investigate their own policyholders! Auto insurance? In a car accident - even not your fault? Even your own attorney, whom you think represents YOU but in reality represents your insurance company, investigates you (it's called due diligence and first thing obtained is your DMV status and record for as long as you've been driving). Home insurance? Did people miss the fact that homeowner insurance companies surveil insured properties via drone and make collect kickbacks from "approved" contractors having informed the homeowner their "roof is bad and we're canceling you in 48 hours." Life insurance? You would not believe what those companies put survivors through when claiming. Any old excuse to not pay will do - or no excuse at all, just stonewalling or litigating or claiming 'fraud.' People somehow continue to believe that insurance is your "friend" - a myth supported by those touchy-feely TV commercials. ALL insurance companies' profits are from collecting premiums and refusing payouts.
AND, State Farm is my grandad, father , uncle , 2 sisters , and Mom at one point ! Who do I have ? NOT THEM . We waited last , for any help , and a roof , after hurricane Andrew , bc we were family connected . NO BENEFIT TO US . Also, sent a secretary from KC to "inspect things" , total incompetent ! Not an adjuster or roofer .
With free healthcare, Medicaid recipients are the least healthy of all demographics. Ironically, it’s the same with all and any type of managed care, we’re all sicker for it!
They have NO accountability , and sleep well at nite , screwing the patients again and again. I heard one tell a PET scan patient "Oh , its just glucose " In the IV . SRSLY LIED BY OMISSION . PLUS COULD HAVE HELPED THAT MAN , and deliberately chose not to.
Medicaid is now almost completely "managed care" whereby upfront dollars in the billions via capitation payments go to a myriad of privatization players both for profit and non profit: from the for profit insurance/tech/pharma/contracting companies to the non profit sector including county/local plans, hundreds if not thousands of quangos including ngos, cbos and various other "stakeholder" entities and continual newly created government agencies with "new programs", especially in the largest Medicaid state of CA with 15 million recipients.
There is no oversight in Medicaid. Please see Georgetown links below.
The Georgetown links report on CMS and state Medicaid reinforces the view of most Medicaid agencies as publicly owned, but not publicly controlled. CMS and MedPAC are also controlled by privatization advocates (both for profit and non profit) and the public has almost no access to reliable information about how all these entities spend valuable Medicaid dollars.
Schneider himself has identified three serious problems with privatized Medicaid programs: (1) Many states don't impose minimum MLRs on Medicaid MCOs, and some of those that do don't demand payment from MCOs that allow their MLRs to fall below the minimum; (2) MLR reports are not posted by CMS; and (3) MLR reports are gamed to make overhead costs look lower than they are.
Medicaid privatization has been underway for more than four decades now (actually started in CA in 1973) where almost of all Medicaid enrollees are mandated into "managed care" but even a dogged researcher like Schneider can't get his hands on reliable information about where the money goes once it disappears down the rabbit hole that is Medicaid managed care.
"How is this large—and growing—public investment in Medicaid managed care being spent? How much of the capitation revenues received by MCOs during the PHE are going toward medical care and quality improvement, and how much is going toward administrative overhead and profit? These are the questions that the medical loss ratio (MLR) metric is designed to answer. Currently, state Medicaid agencies have the option of requiring MCOs to meet an MLR of at least 85 percent and, if an MCO fails to do so, requiring the MCO to remit any excess capitation payments to the state. (A state and the federal government share in any remittances in proportion to the state's federal matching rate). A recent HHS Office of Inspector General report found that, as of September 2020, six Medicaid managed care states (GA, KS, RI, TN, TX and WI) did not require MCOs to meet a minimum MLR, and five of the 36 states that did impose a minimum MLR did not require remittances from MCOs that did not meet the minimum. Of the MCOs subject to minimum MLRs, 39 did not meet their target, and 19 reported owing a total of $198 million to six states."
To add to the above nbc report about "fraud and abuse" that is Medicaid managed "care" in CA I'd like to add a recent SF Chronicle article by 2 very young journalists document a typical scenario for the " Behavioral Health" in Medicaid managed integrated care in CA. The SF Chronicle also does not mention "Medi-CAL" or Medicaid specifically but that is where all the Medicaid billions are going right now---the exploding Behavorial Health market.
Even though the article does a good job of detailing the horror story of this young women's life by the so called health care system, it actually has some facts wrong as far as I can tell. After a quick cursory google search of the 10 hospitals that are listed I found the vast majority (at least 7 ) to be "non profit" hospitals and some of the for profit ones are "guided" by non profit organizations/foundations. Someone may want to check this for themselves.
And the Dallas News has always done a good job of keeping an eye on the abuse that is Managed 'care" Medicaid. An old article but nothing has changed---except for the worse:
I would disagree. It is not confusion, it is very deliberate policy by government on both the federal and state levels coupled with both the forprofit and nonprofit industries. I realize it is easier to see the corporate forprofits as the boogie man in this but as I keep trying to impart the nonprofit industry is huge. Privatization is caused by both.
Yes of course this well thought out (deliberate) confusion has lead us all into a policy of corporate greed. My grandma (born in 1900) told me the doctor’s fee was a sack of potatoes to help deliver a baby.
Would also point out a new Medicare [dis]Advantage tactic involving Medicaid. First the MA companies claim "hundreds of available physicians" but when that turns out to be a falsehood they refer policyholders to alleged "primary care doctors" available - turns out those are only in "public health clinics." Meaning Medicaid clinics. Commence unresolvable confusion in "paperwork" and eventual nastygram from an "official" accusing the patient of "misrepresenting" themself as being Medicaid eligible. MA policyholders, keep a record of everyone you speak with at your MA insurer: name, date, time of conversation. It may save you from future false accusations with threats of "prosecution." This is apparently MA's strategy to re-route possible claim payouts from MA to Medicaid.
Yep, that tactic of giving a list of available physicians (which turns out most of them are not, or don't even exist) in Medicaid managed care plans has been going on for the past 15 years in Medicaid managed care, esp. in CA. Many of the tactics and policies that CMMI has been trying to implement (like DCE's or ACO REACH, etc.)into Medicare have been taken right out of CA's playbook on how they forced us all into Medicaid managed "care" since 2010.
KAISER PERM is so onto this one !! Advertise lots of physicians , even post thier photos on the walls in wait areas , but really none you may see. "Doing research now" "Not accepting new patients now " "He's only admin now " "She's quit now " etc etc etc
Considering that the public health systems have become the "employer for all" including both the for profit and non profit sectors and the burgeoning "government agencies" like in the state of CA---there would have to be strident budgetary controls and simplifying of the over all system. Given the increase and proliferation of tech in the HHS sector in the past 10 years, I wonder if having only"one payer" is even possible anymore when it comes to financial savings, one of the under pinnings of what a one payer system would have given us back 20 years ago. The HHS sector is the largest employer in the US now and that doesn't even include the tech sector's presence. In other words, just about everybody has got their hand in the pot save for the poor disabled, and elderly who are desperately in need and where the "dollars" should be directly going to, as detailed in some of the links in my initial post.
It is not blackmail, it is against both Medicare and Medicaid statute and has been since their inception. In my opinion mandated/forced Medicaid managed "care"or any mandated managed "care" as it is CA. is against federal statute. Please read below:
"The Center for Medicare Advocacy joined the National Health Law Program and numerous other health organizations in urging the Supreme Court to confirm that individuals may sue to enforce Medicaid’s “free choice of provider” provision. The “freedom of choice” provision establishes beneficiaries’ right to obtain services from any health care provider who is qualified to offer those services and is enrolled in the Medicaid program. The same provision exists for beneficiaries in Medicare. Congress incorporated the right to choose one’s medical provider into Medicare and Medicaid over 50 years ago. In Medina v. Planned Parenthood of South Atlantic, the U.S. Supreme Court will decide whether Medicaid beneficiaries can enforce the freedom of choice provision in court. Under the Court’s holding in another recent case, individuals should be able to enforce this right in court.
I do find that bribes help . Individuals need to be scene , and listened to, not ignored or replaced w higher paid OUT OF STATE travelling nurses , techs , etc .
I completely agree with your statement at the end. The circumstances are salacious, but it is the result of Profit over Patient mentality in for-profit-run healthcare insurance and services for our most vulnerable (Medicare and Medicaid)
It's like cockroaches. If you catch one, you know there are thousands more behind the walls. If anyone wonders why so many people metaphorically high-fived the accused murderer of United Healthcare's CEO, look no further than this slimy example of healthcare privateering. Original Medicare for everyone! Thank goodness I have lived long enough to have original Medicare. I will not ever choose Medicare Advantage. I resent my tax dollars yet again fattening private profits (Medicare Advantage) while siphoning off money that could be directed toward actual healthcare. Raise taxes on the 1 percent and neither Medicare nor Social Security would have funding problems!
MOST intelligent comment ever posted ! YES !!
Thank you.
Yet another reason private insurers need to stay out of our government health care. Medicare (dis)Advantage also. We need one health plan to cover all of us!
Why is anyone surprised? ALL insurance companies surveil and/or investigate their own policyholders! Auto insurance? In a car accident - even not your fault? Even your own attorney, whom you think represents YOU but in reality represents your insurance company, investigates you (it's called due diligence and first thing obtained is your DMV status and record for as long as you've been driving). Home insurance? Did people miss the fact that homeowner insurance companies surveil insured properties via drone and make collect kickbacks from "approved" contractors having informed the homeowner their "roof is bad and we're canceling you in 48 hours." Life insurance? You would not believe what those companies put survivors through when claiming. Any old excuse to not pay will do - or no excuse at all, just stonewalling or litigating or claiming 'fraud.' People somehow continue to believe that insurance is your "friend" - a myth supported by those touchy-feely TV commercials. ALL insurance companies' profits are from collecting premiums and refusing payouts.
ALSO, just TRY to get decent storm insur in FLORIDA / doesn't exist !!!!!
AND, State Farm is my grandad, father , uncle , 2 sisters , and Mom at one point ! Who do I have ? NOT THEM . We waited last , for any help , and a roof , after hurricane Andrew , bc we were family connected . NO BENEFIT TO US . Also, sent a secretary from KC to "inspect things" , total incompetent ! Not an adjuster or roofer .
With free healthcare, Medicaid recipients are the least healthy of all demographics. Ironically, it’s the same with all and any type of managed care, we’re all sicker for it!
Money and Power Corrupt.
There is an astounding amount or crime and greed. Anyone that works for a healthcare corporation should quit.
They have NO accountability , and sleep well at nite , screwing the patients again and again. I heard one tell a PET scan patient "Oh , its just glucose " In the IV . SRSLY LIED BY OMISSION . PLUS COULD HAVE HELPED THAT MAN , and deliberately chose not to.
Medicaid is now almost completely "managed care" whereby upfront dollars in the billions via capitation payments go to a myriad of privatization players both for profit and non profit: from the for profit insurance/tech/pharma/contracting companies to the non profit sector including county/local plans, hundreds if not thousands of quangos including ngos, cbos and various other "stakeholder" entities and continual newly created government agencies with "new programs", especially in the largest Medicaid state of CA with 15 million recipients.
There is no oversight in Medicaid. Please see Georgetown links below.
The Georgetown links report on CMS and state Medicaid reinforces the view of most Medicaid agencies as publicly owned, but not publicly controlled. CMS and MedPAC are also controlled by privatization advocates (both for profit and non profit) and the public has almost no access to reliable information about how all these entities spend valuable Medicaid dollars.
Schneider himself has identified three serious problems with privatized Medicaid programs: (1) Many states don't impose minimum MLRs on Medicaid MCOs, and some of those that do don't demand payment from MCOs that allow their MLRs to fall below the minimum; (2) MLR reports are not posted by CMS; and (3) MLR reports are gamed to make overhead costs look lower than they are.
Medicaid privatization has been underway for more than four decades now (actually started in CA in 1973) where almost of all Medicaid enrollees are mandated into "managed care" but even a dogged researcher like Schneider can't get his hands on reliable information about where the money goes once it disappears down the rabbit hole that is Medicaid managed care.
https://ccf.georgetown.edu/2022/10/06/medicaid-managed-care-oig-mlrs-and-the-future-of-oversight/
"How is this large—and growing—public investment in Medicaid managed care being spent? How much of the capitation revenues received by MCOs during the PHE are going toward medical care and quality improvement, and how much is going toward administrative overhead and profit? These are the questions that the medical loss ratio (MLR) metric is designed to answer. Currently, state Medicaid agencies have the option of requiring MCOs to meet an MLR of at least 85 percent and, if an MCO fails to do so, requiring the MCO to remit any excess capitation payments to the state. (A state and the federal government share in any remittances in proportion to the state's federal matching rate). A recent HHS Office of Inspector General report found that, as of September 2020, six Medicaid managed care states (GA, KS, RI, TN, TX and WI) did not require MCOs to meet a minimum MLR, and five of the 36 states that did impose a minimum MLR did not require remittances from MCOs that did not meet the minimum. Of the MCOs subject to minimum MLRs, 39 did not meet their target, and 19 reported owing a total of $198 million to six states."
https://ccf.georgetown.edu/2021/08/18/hidden-in-plain-sight-a-medicaid-managed-care-pay-for/
https://ccf.georgetown.edu/2023/05/24/a-closer-look-at-the-medical-loss-ratio-mlr-provisions-of-cmss-proposed-medicaid-managed-care-rule/
______________________________________
Current example of blatant fraud and abuse that is Medicaid managed "care" in CA: https://www.nbcbayarea.com/investigations/costa-contra-health-doj-investigation/3740234/.
To add to the above nbc report about "fraud and abuse" that is Medicaid managed "care" in CA I'd like to add a recent SF Chronicle article by 2 very young journalists document a typical scenario for the " Behavioral Health" in Medicaid managed integrated care in CA. The SF Chronicle also does not mention "Medi-CAL" or Medicaid specifically but that is where all the Medicaid billions are going right now---the exploding Behavorial Health market.
https://www.sfchronicle.com/projects/2025/california-psychiatric-hospitals-jazmin-pellegrini-death/
Even though the article does a good job of detailing the horror story of this young women's life by the so called health care system, it actually has some facts wrong as far as I can tell. After a quick cursory google search of the 10 hospitals that are listed I found the vast majority (at least 7 ) to be "non profit" hospitals and some of the for profit ones are "guided" by non profit organizations/foundations. Someone may want to check this for themselves.
And the Dallas News has always done a good job of keeping an eye on the abuse that is Managed 'care" Medicaid. An old article but nothing has changed---except for the worse:
https://interactives.dallasnews.com/2018/pain-and-profit/part1.html
https://interactives.dallasnews.com/2018/pain-and-profit/part2.html
https://interactives.dallasnews.com/2018/pain-and-profit/part3.html
Again, an old article but still pertinent and even worse today:
https://khn.org/news/as-billions-in-tax-dollars-flow-to-private-medicaid-plans-whos-minding-the-store/
We understand all this confusion is by design of for-profit private health insurance companies
I would disagree. It is not confusion, it is very deliberate policy by government on both the federal and state levels coupled with both the forprofit and nonprofit industries. I realize it is easier to see the corporate forprofits as the boogie man in this but as I keep trying to impart the nonprofit industry is huge. Privatization is caused by both.
Yes of course this well thought out (deliberate) confusion has lead us all into a policy of corporate greed. My grandma (born in 1900) told me the doctor’s fee was a sack of potatoes to help deliver a baby.
Would also point out a new Medicare [dis]Advantage tactic involving Medicaid. First the MA companies claim "hundreds of available physicians" but when that turns out to be a falsehood they refer policyholders to alleged "primary care doctors" available - turns out those are only in "public health clinics." Meaning Medicaid clinics. Commence unresolvable confusion in "paperwork" and eventual nastygram from an "official" accusing the patient of "misrepresenting" themself as being Medicaid eligible. MA policyholders, keep a record of everyone you speak with at your MA insurer: name, date, time of conversation. It may save you from future false accusations with threats of "prosecution." This is apparently MA's strategy to re-route possible claim payouts from MA to Medicaid.
Yep, that tactic of giving a list of available physicians (which turns out most of them are not, or don't even exist) in Medicaid managed care plans has been going on for the past 15 years in Medicaid managed care, esp. in CA. Many of the tactics and policies that CMMI has been trying to implement (like DCE's or ACO REACH, etc.)into Medicare have been taken right out of CA's playbook on how they forced us all into Medicaid managed "care" since 2010.
KAISER PERM is so onto this one !! Advertise lots of physicians , even post thier photos on the walls in wait areas , but really none you may see. "Doing research now" "Not accepting new patients now " "He's only admin now " "She's quit now " etc etc etc
How about one payer only.
For-profit private health insurance companies dropped elderly in the 1960’s that is why Medicare was necessary.
Most of these companies today fight for all the corporate welfare the ccan take
Considering that the public health systems have become the "employer for all" including both the for profit and non profit sectors and the burgeoning "government agencies" like in the state of CA---there would have to be strident budgetary controls and simplifying of the over all system. Given the increase and proliferation of tech in the HHS sector in the past 10 years, I wonder if having only"one payer" is even possible anymore when it comes to financial savings, one of the under pinnings of what a one payer system would have given us back 20 years ago. The HHS sector is the largest employer in the US now and that doesn't even include the tech sector's presence. In other words, just about everybody has got their hand in the pot save for the poor disabled, and elderly who are desperately in need and where the "dollars" should be directly going to, as detailed in some of the links in my initial post.
But who told the state to contract with the MCOs? The state legislature. Ignore the pearl clutching by them.
Now UnitedHealthgroup is advertising primary care for seniors thru Archwell. Archwell will not accept my original Medicare. I feel this is blackmail.
It is not blackmail, it is against both Medicare and Medicaid statute and has been since their inception. In my opinion mandated/forced Medicaid managed "care"or any mandated managed "care" as it is CA. is against federal statute. Please read below:
"The Center for Medicare Advocacy joined the National Health Law Program and numerous other health organizations in urging the Supreme Court to confirm that individuals may sue to enforce Medicaid’s “free choice of provider” provision. The “freedom of choice” provision establishes beneficiaries’ right to obtain services from any health care provider who is qualified to offer those services and is enrolled in the Medicaid program. The same provision exists for beneficiaries in Medicare. Congress incorporated the right to choose one’s medical provider into Medicare and Medicaid over 50 years ago. In Medina v. Planned Parenthood of South Atlantic, the U.S. Supreme Court will decide whether Medicaid beneficiaries can enforce the freedom of choice provision in court. Under the Court’s holding in another recent case, individuals should be able to enforce this right in court.
Read more, and download the Brief at medicareadvocacy.org/center-for-medicare-advocacy-supports-beneficiaries-right-to-sue-again"
I do find that bribes help . Individuals need to be scene , and listened to, not ignored or replaced w higher paid OUT OF STATE travelling nurses , techs , etc .
Excellent coverage of the dirty little secrets in US
"health care" . SRSLY PEOPLE ? How could it get worse !!!!!