How Genetic Testing Will Destroy the Insurance Industry

Ever been denied insurance coverage (or had your rates hiked up) for a preexisting condition? Or because certain illnesses run in your family? Well now you can be rejected for a condition that wasn’t even on your radar.

Over 700,000 Americans have already had genetic testing done to determine if they are at risk for certain diseases, like Alzheimer’s or some cancers. Naturally, once given the news that they are genetically predisposed to get a disease, people are much more likely to purchase insurance against future care needs. Insurance companies don’t like this. They make money on the uncertainty of the future: people who want protection against the possibility of becoming very ill, without yet knowing if they will be healthy or not. But when applicants know they have a higher chance of getting a disease, it stacks the deck against insurance companies. It’s not good for business.

Fortunately for insurers – and unfortunately for most everyone else – there is nothing stopping providers from seeing those test results for themselves. While federal law does prohibit genetic discrimination when purchasing health insurance, there’s no such protection when buying for long term care, disability, or life insurance. Even scarier, in some cases companies will require applicants to get tested before they even consider them for coverage. This eliminates much of their risk; anyone with the gene for Alzheimer’s, for example, can be flat out denied or offered rates so high as to be largely unaffordable. Since these are almost exactly the people who will use the coverage, there is a much lower risk of payout for the insurer. However, it leaves individuals with looming care expenses in a desperate situation.

A few states have protections in place for consumers, and Vermont has completely outlawed the practice. However, this is the exception to the rule. There are those that would have genetic discrimination banned nationwide, which could be very bad for everyone. If genetic testing results are for the consumers’ eyes only, insurance companies will inflate their rates against the higher risk they are taking. If you think insurance is unaffordable now, just wait.

While having a specific gene is not a guarantee of illness, nor is lacking the gene a guarantee of health, the insurance market will become woefully unbalanced and unstable. The urge to stick large companies with the bill is popular, but if there is no money to be made, insurers will stop writing policies. That leaves the common man with one less protection against the overwhelming reality of getting very sick later in life. With genetic testing on the cusp of a giant boom, the business of insuring people against their worst nightmares is more of a daydream than a reality.

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Defrauding Medicare: A How-to Guide

If you’re looking for a get rich quick scheme with low risk, Medicare fraud is the way to go. There’s big pot of money out there and the system is ill-equipped to notice incorrect charges, especially before payments are made. With nearly 5 million claims daily and only 30 days to process each one, Medicare pays quickly and easily. It is estimated that Medicare spends $58 billion a year on improper payments. Here’s how to get your piece of that overflowing bounty.

 

Set up a medical office: A pharmacy, doctor’s office, or medical supply store will work. You’ll never need to open the doors or move in, you just need the address to bill from. South Florida is a great area to set up your business; there’s around one provider for every 500 Medicare patients, as opposed to one in 3000 for the rest of the country, so their offices are overextended with claims. It will also reduce your risk if you find someone else to put his name on the paperwork; there’s a wealth of recent immigrants in southern Florida you might convince your operation is perfectly legal.

 

File with Medicare as a provider: Close to 45,000 providers apply every month; they do not have the resources to check into your credentials.

 

Get legitimate IDs: You’ll need lists of patients’ Social Security numbers and doctors’ billing ID numbers. They are readily available on the black market. It’s important to get a current list, as billing for deceased patients and retired doctors has gotten some of your competitors in hot water.

 

Start billing: The trick is to know your billing practices. While it’s unlikely that anyone will check in when you set up shop, incorrect billing procedures will get Medicare’s attention – attention you don’t want. And don’t get too greedy; even Medicare will notice if you bill millions of dollars in a month.

 

Collect your checks. Remember, Medicare is required to send out payments within 30 days of a claim. It won’t take long for your paychecks to come in. If an investigator does start poking around, it’s easy enough to walk away and set up shop somewhere else.

 

Medicare spending is a hot topic in Congress. Presidents keep proposing cuts (and some even go through), but this really won’t affect your bottom line. Medicare’s fraud prevention budget is about 0.2% of their total spending, while expenditure on improper claims is estimated at 10% of their budget (and it’s likely a lot more). Some argue that increasing the fraud prevention budget would decrease such spending, but it hasn’t been a popular idea in Congress. It’s easier to cut the entire budget than it is to overhaul the system and stop improper payments.

Credit card companies’ fraud loss rating is right around 1%. Anti-fraud practices have made it difficult to steal from these companies and more likely you’ll get caught. Medicare’s much higher loss rating and lack of funding for fraud prevention make it a much riper and safer peach, just waiting to be picked.

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You Won’t Believe What Nursing Homes Are Doing to Get Paid

Ever had a bill collector assume guardianship over you so they could pay themselves with your money? It’s hard to imagine, but it is a practice nursing homes employ when patients don’t pay their bill – and it is legal. Be it a dispute over charges, lack of cooperation, or just plain refusal to pay, a facility can gain power of attorney without the consent of patients or their families, and then they have control over how the patient’s money is spent. And the first thing they do is pay themselves.

The New York Times recently reported on the case of Lillian and Dino Palermo, a good example of the abuse of the law that nursing homes are perpetrating. After Mrs. Palermo’s dementia progressed to a point where her husband couldn’t care for her alone, Mr. Palermo made the difficult decision to move his wife into a nursing home. After a time, the home changed their monthly fee claiming Mrs. Palermo was receiving more care. Mr. Palermo disagreed with the charges. While he had the bills reviewed, he refused to pay the rate the nursing home asked. One day, he came into his wife’s room to find a legal petition on her bed stating that the nursing home was filing for guardianship over Mrs. Palermo. He was shocked. Mr. Palermo fought the petition, at his own expense. While the court battle raged on, the review of Mrs. Palermo’s care bills was completed and Mr. Palermo paid the remaining balance (which was less than the nursing home claimed he owed). The petition for guardianship was immediately withdrawn.

It is obvious that the nursing home’s sole concern was to get paid, and they used the cruelest of tactics to make sure it got done. This case is not unique. It is hard to determine just how often it happens because many such cases are cloaked under the veil of patient privacy rights. The lawyer trying the Palermo case spoke to the Times about his experience; he estimated that he had brought 5000 such cases to trail in his 21 years of practice. Another independent study is underway and the researchers shared some preliminary findings. Over a ten year span, they found that 3,302 guardianship cases were filed in Manhattan; nursing homes were the petitioners in 12.4% of those cases – that’s more than 400 times, just in one section of one city in the nation. While there are legitimate reasons to file such petitions, those familiar with the field agree that the primary purpose is bill collection.

If the court approves guardianship, it takes precedence over previous arrangements made by the patient, such as the power of attorney and health care proxy Mrs. Palermo had set up naming her husband as her guardian. People need to be aware of this possibility when a loved one is in a nursing home. The problem is not widely known, and families can find themselves unprotected and without the means to fight back. Mr. Palermo fought, but it cost him $10,000 and a great deal of worry and stress. It’s hard to say what would have happened if the nursing home had not withdrawn their petition. Mr. Palermo was determined to fight to the end, but his pockets are certainly not as deep as the nursing home’s.

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Seniors and Vaccines: an Infographic

The debate about the effectiveness and safety of vaccines rages on. Opinions vary wildly about their usefulness for children and the nation as a whole. Recent outbreaks of measles have brought the issue front and center in the media, but not many people are talking about the effect on the elderly population. So what do vaccines do for seniors? Are they beneficial for those with an aging and weakening immune system, or do they open people up to more illness than they protect against? Here’s a few facts to consider when debating whether you or someone you care for should be vaccinated:

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Why are 6000 US children living in nursing homes?

It’s hard to imagine children growing up in nursing homes, never mind dying there. But right now there are over 6000 kids living in medical facilities for the elderly, according to federal data. These are sick children, in need of high levels of medical care to survive each day; nursing homes are not the best place for them, but they are better than every other option their parents have. Nursing homes for the elderly are specifically designed to handle complex and time consuming medical needs, but they are not intended to meet needs specific to children.

It can also be hard to find a nursing home willing to take a child, and sometimes kids end up far from home and family. Zach moved into a nursing home at ten years old because his needs were too intense for most child care programs, and his mother had to keep her job for the insurance that paid his medical care – not to mention provided food and a place to live. The state would not pay for at home care and the only place that would take him was 200 miles away in another state. His mother made the trip every 2-3 weeks to visit and meanwhile tried every way she could think of to bring him closer to home. When Zach turned 21, after eleven years in a home for the elderly, he was no longer eligible for the children’s program that had supported him, and his care deteriorated. He spent most of his time in bed and got sicker. His mother’s primary fear was not so much that he would die, but that he would be alone when it happened. A program that would allow him to receive care at home became available, but Zach had lived out of state for so long that he was not eligible. He would have to live in an in-state facility while waiting on a list, thousands of people long, to get into the program. At 25 he died in the nursing home waiting for his chance.

Bylon was six years old when she had a stroke. She received care at home until her mother got sick and was hospitalized. Bylon had to move into a nursing home and not too long after that, her mother died in the hospital. On the day of the funeral, aides got her dressed and ready to travel, but the van to pick her up never came and she missed her mother’s funeral. She wanted out of the nursing home badly, but there was no one to take care of her. At 23, Bylon got into a program that would pay for an accessible apartment and aides, but there was a waiting list. She was excited to live her own life, for the first time since she was six. She aspired to finish high school and go to college. A year later, Bylon died in the nursing home.

Nursing homes are designed to take care of the elderly. Typically, patients are tended to for medical and basic personal needs and left to themselves the rest of the day. Activity programming is geared toward the interests of people over 60, not under 10. There is no friendship, no social time, no education, and not many visitors. There is no childhood in a nursing home. However, there is life. When there is no other alternative, placement in a nursing home saves kids’ lives; having a place to turn in desperation is a godsend. Most parents are fortunate enough not to have to consider sending their child away to live in such an environment, and because the problem only affects a small percentage of the population, better solutions (like youth nursing homes) are not well funded. Where else are desperate families to turn? Until there is a better solution, children will continue to be sent away from the familiarity and relative comfort of home to live in a facility amongst the sick and dying.

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Over Medicating Seniors Makes Caregiving Easier

Antipsychotic drugs are a dangerous treatment for dementia patients – they increase risks for heart failure, infections, and death. And they do absolutely nothing to improve dementia. Yet in 2011 nearly 88% of Medicare claims for antipsychotic drugs given in nursing homes were to treat dementia patients. Why?

The reason is disturbing and appalling. Doctors in nursing homes prescribe antipsychotic drugs to dementia patients to make them easier to handle. It is much simpler for nursing home staff to monitor and care for a person who is drugged into a stupor. They don’t get confused or agitated, wander away, or resist treatment. They simply sit without complaining. It is called chemical restraint, and it is against the law.

After the 2011 study, the government decided to crack down and stop this dangerous behavior. But the solution has no teeth. Take the example of Texas, whose nursing homes have the highest rate of antipsychotic drug use in the US. An independent analysis of Medicare claims and payments has shown that Texas nursing homes are actually less likely to be censured for their misuse of drugs than most other states. In fact, only 2% of infractions were rated at a level that incurred a fine when state inspectors made their visits. CMS’s approach is one of collaboration with states. The Chief Medical Officer said, “There are many near misses…where medication might be given that’s not needed and doesn’t cause permanent harm. We view that as a learning opportunity.” An alternative view: it is illegal and harmful to patients.

But Medicare keeps paying for it. In one six-month period, they paid $116 million, and they keep doing it. CMS would rather partner with states to reduce claims over time than put a halt to this unconscionable behavior right now. It’s not hard to imagine what would happen if Medicare started denying the claims. It is, however, very hard to imagine why they continue to approve them. My insurance company won’t pay for medicines that they believe I don’t need – since when does Medicare?

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Medicaid: Taking Your Inheritance Since 1965

It’s hard to imagine a person who is poor enough to qualify for Medicaid passing their medical debt down onto their children, but it happens. One woman whose mother had recently passed was handling the sale of her mother’s home. Her mother had been ill for the last few years of her life and rather than go to an expensive nursing home, she had aides come by to help her out. There were doctors’ bills and prescriptions, all covered by Medicaid once she qualified. After the mother’s death, the woman received a bill for over $85,000 that Medicaid said she had to pay for her mother’s care. It came as a shock, but it is completely legal.

States are actually required to try and recoup cost of care from the estates of people who die having received Medicaid after turning 55. In order to qualify for Medicaid, a person must have very little in the way of assets. However, it is allowable to own a home and still receive benefits. But after death, the state will send a bill for the cost of care; this can mean assets from the sale of a house go to the state.

This regulation has actually been around since Medicaid began, but was used very little because it only affected people over 65 (now it’s 55), few of whom qualified for Medicaid in the first place. But with recent expansions to Medicaid, more people are falling into this category and should be aware of the possibility.

While states are required to make an attempt to recoup their costs, the effort they must put into it is not established. Some only go so far as to send a bill. Ten states so far have indicated that they will be following up on claims and seeking retribution. Others are holding off due to the costs involved in pursuing reimbursement and the fact that a good portion of the money they get back goes straight to the federal government anyway.

This practice has already begun to discourage people from signing up for Medicare, which puts a lot of people in a tough spot. Anyone will attest to the exorbitant cost of medical care these days. Trying to get by without Medicaid lands people in serious debt, and creditors will not wait until you pass away to collect their due. Medical bills are the number one reason individuals file bankruptcy in the US. Overall, Medicaid is still the right choice for people in need, but it is important to be aware of the potential cost to your heirs. There is a small chance it will cost your kids a little inheritance, but it will improve your healthcare options and financial stability while you are still alive.

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Can You Get a Sex Change on Medicare?

The short answer…Yes. Until recently the federal government refused payment for such treatments claiming they were controversial and unproven. Now the ban has been lifted so the decision comes down to regional judgment. Some areas have jumped to allow it, while others are playing wait-and-see. Nine states have even gone as far as to declare that insurance companies covering mental illness cannot decline transgender operations as treatment; New York is the most recent to join in, pending a public comment period of 45 days.

So what does the public think? Be it proven treatment or not, gender related issues are a hot button topic and not everyone is happy that their tax dollars will be paying the bills. As you might imagine, public opinion runs the gamut. Here are a few remarks that are representative of the greater range of opinions:

“If it bothered them that much then they should have saved up money while they were younger and paid for the surgery themselves. Obviously it wasn’t that important to them or they would have done that. Our government is 17 trillion dollars in debt. We don’t need to add to that debt by paying for elective cosmetic surgery. It’s ludicrous.”

“…providing trans gender people the gender reassignment surgery (below the waist) and providing them with the drugs needed for the transition is acceptable BUT the other services like permanent hair removal, breast and buttocks augmentation, and all facial cosmetic surgery should not be paid for by any health insurance company or medicaid. Why, because the insurance companies do not provide these services for others who want or need it; providing these services for a select few individuals while excluding all the others is unfair, biased and sexist…”

“Medicare, in my jurisdiction, doesn’t cover anxiety or depression. Why would they (me) pay for a surgery to make someone (you?) happy? How about a face lift too…enlighten me as to why tax payer money should pay for this and not other procedures that are pertinent to a patient’s health?”

“Do you think the same thing about things like hip and knee replacements or corneal implants? Where do you draw the line on what conditions should be treated and what should not.”

“My wife suffers from depression because her breasts are smaller than what she would like them to be. So will medicare cover her boob job so she’ll have more confidence in herself?”

“It’s a biological condition that’s formed in the womb when sex traits start to develop.”

“Please somebody tell me this is a joke. We have veterans DYING waiting for appointments and this administration wants to spend taxpayer money on ELECTIVE SURGERY?”

“No. Just NO.”

Public forums slant rather heavily toward the outraged and sarcastic, but there are voices of agreement as well. Whether or not the law passes the public comment period in New York, more insurers – Medicare and Medicaid included – are covering sex change surgery and hormone therapy as treatment for a mental disorder. So, as it turns out, even the long answer is: Yes, you can get a sex change on Medicare.

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Sexual Assault in Many Nursing Homes Goes Uninvestigated

In Washington State an 83 year old dementia patient was raped, and it was caught on film. The family of the victim had suspected abuse and so they set up a hidden camera. The result was a video of the facility’s owner sexually attacking the elderly woman. Authorities arrested the man, shut down the facilities he owned and ran, and sent all remaining patients to the hospital to be checked for signs of abuse. This instance was handled with swift action, but sadly this is the exception to the rule.

A study was done in Chicago nursing homes and found that over a two-and-a-half year period authorities investigated 86 cases involving sexual assault of a resident. Of those cases, only one led to an arrest. Eighty-five people were reported as victims of sexual assault and found no justice. The study found that the vast majority of these crimes were perpetrated by another resident who forced his way into a woman’s room or abused her while staff was not nearby. Incidentally, the one case that was actually prosecuted was one in which a staff member was accused. Outside of nursing homes, Chicago police make approximately one arrest for every three reports of sexual assault filed. There is a huge disconnect between typical arrest patterns and those in nursing homes.

The study dug a little deeper into the locations where assaults were reported.  Instances of rape were found to be reported from only 30 of the 119 communities in Chicago, and these particular locations were twice as likely to have residents who were felons or mentally ill. They also have substandard staffing as compared to those where rapes were not reported. A picture is painted of predators roaming around unchecked, terrorizing the elderly, the sick, and the helpless.

In one instance, a 28 year old man confessed to beating and raping a schizophrenic elderly woman in the facility where he lived. The woman corroborated the story at the time, but was not as cooperative later in the investigation. Despite the confession and physical evidence to back it up, no arrest was made.

Another case involves a dementia patient in hospice care. A call reporting sexual abuse was made to the nursing station of the facility in which she lived. The head nurse did nothing for one whole day. The victim was bathed, her clothes were laundered, and her room was cleaned – in other words, the evidence was removed. The alleged perpetrator was allowed to continue caregiving duties in the area where the victim lived. After a full day, the patient was sent to the hospital for a routine physical, not for a suspicion of assault. It was only when the hospital declined (she was not due for her exam) did the story come out. Even then, the nurse only called authorities after the hospital threatened to do so themselves.

Cases like these are fraught with problems for law enforcement. Victims are often mentally ill, afraid for their safety (as they live with the rapist), or unwilling to cooperate. However, it is appalling and unacceptable to allow this type of behavior to go unchecked, especially in cases where the supposed caregivers are turning a blind eye to the problem. Instances where staff members impede the investigation should be treated extremely harshly. Losing a job or a license is not enough; there ought to be criminal culpability for helping a predator to escape.

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Sex Is the New Bingo

Retirement isn’t just card games and gardening anymore. The flower children of the ‘60s are now filling up assisted living communities and they are definitely making love, not war. According to the National Survey of Sexual Health Behavior, over half of men and forty percent of women above 60 are sexually active. Put all those consenting adults together into an apartment complex 24/7, and it becomes more like a college frat house than a nursing home!

The abundance of sex is not the problem by itself, but the spread of disease is a concern. Senior citizens are charging ahead with astonishing growth in STDs, and the trend isn’t going soft. Numbers reported from the CDC show that over a four year period chlamydia infections among the senior population grew by more than 30% and syphilis cases rocketed upwards by 52%. HIV has been on the rise as well. The generation now in retirement received far less sex education than those coming up behind. Aside from warnings about ladies in foreign ports, there was no talk of safe sex for this group. Studies show that across all age groups, condoms are used about 40% of the time, but in the senior population they are only used in 6% of sexual encounters. Medicare does offer free screenings for STDs, but that seems akin to a morning-after pill, and only about five percent of qualified people use them anyway.

So why the sudden rise in…figures, shall we say? The most obvious answer would be the assortment of pills for male performance that were not as widespread in previous generations. Overall health and mobility are improved, as well. More senior men are physically able to have sex, and post-menopausal women with no fear of pregnancy are abundant. Besides, sex is fun! Just because you don’t think of grandma as a minx between the sheets, doesn’t mean she hasn’t learned a thing or two in her time.

There seems to be an untapped market for condom education and sales here. A vending machine in every retirement community? Or maybe housekeeping could leave something besides a mint on the pillow when they clean apartments? Whatever your personal opinion on the matter, Bingo is out – sex is fast becoming the favorite activity of retirement communities!

 

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