Pharmacy Benefit Managers Are Not Much More Than “Complex Well-Greased Algorithmic Human Scoring Machines” That Deny or Allow Access To Drugs To Create/Substantiate Big Corporate Profits

<p>So let’s get down to what’s really happening here.  Once upon a time the PBM models were a different type of creature but as time moved on they became less about a better and affordable price for prescriptions and more about and algorithmic machine to create profits, hidden for the most part as we can’t see the transactions written in computer code where every execution comes along and takes their<a href="https://lh3.googleusercontent.com/-cPuBknPJnJI/WqQR9-82JAI/AAAAAAABNMo/9BxoYmYEPDAeO2VeUBanKlAoH7tehHiYwCHMYCw/s1600-h/image%255B3%255D"><img align="right" alt="image" border="0" height="268" src="https://lh3.googleusercontent.com/-xbwHhvTEeAo/WqQSDg_2GoI/AAAAAAABNMs/E_i8H8PUsT4fEPyQ_XZKR5otSvSnyMC4QCHMYCw/image_thumb%255B1%255D?imgmax=800" style="float: right; display: inline; background-image: none;" title="image" width="395"></a> chunk of money.  United Healthcare created the PBM model back in 1976 under the name of <a href="https://en.wikipedia.org/wiki/Diversified_Pharmaceutical_Services">Diversified Pharmaceuticals</a>, which ended up ultimately being purchased by Express Scripts via SmithKline Beecham.  Express Scripts also purchased another PBM a few years back called <a href="https://en.wikipedia.org/wiki/Medco_Health_Solutions">Medco</a>, so combine all the algorithms with both companies and you end up with a massive collection of algorithmic computer code, there to create profits.  </p><p>It was the feeling that too much corruption and price setting would occur if pharmaceutical companies owned pharmacy benefit managers so they divested themselves of the pharmacy benefit business and it got worse as the PBM businesses moved into the arena of the health insurance companies.  Initially the PBMs were supposed to work as a partner to help insurance companies control costs, but it’s far from that today.  Today all we see is a consumer “scoring” business that found out how to score you by mining and selling all your data to make big profits for the most part.  Sure there’s still drug pricing in the picture, but it’s more about what the market will bear than it is affordability.  What we have ended up with is more of a digital caste system with drugs that goes way beyond negotiating price and helps substantiate a digital caste system that is growing every year in the US.  We don’t have the algorithms and the formulas to fight back and thus as consumers and small businesses we are just mowed under by what’s taking place and we have a Congress that is flat out both too stupid to see it or has been sufficiently bought off by the big conglomerate, or both. </p><p><a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html"><strong>Excess Scoring of US Consumers, US Citizens-Scored into Oblivion By Proprietary Algorithms and Formulas, Never Duplicated or Tested for Accuracy-Profits of Big Business And A White House Executive Command To Continue the Abuse..</strong></a></p><p>It’s hard today to even find really good journalism with the big media as they are all starving for revenue since Facebook came along with all their algorithms and functioned like a PBM to rob them of their advertising revenue so they are hanging on to what’s left on who pays for ads, and it circles right back to big pharma and health insurance companies, and nobody’s going to disturb what left of the golden goose that helps keep their doors open with new stories that give you the real picture today as they will not publish anything that will reduce what advertising revenue that they have left with anything detrimental reported about big pharma and health insurance companies.  As I wrote a while back, news rigging is here, and done with algorithmic models that write the news for them today as well.  It’s like your day trading software, you just plug in what you want and the software will write it up with a focus that you specify, or knock off news is also done this way, taking existing news and putting the bot to work t re-arrange an article (s) that’s already been written to create a new one with a bot that is smart enough to avoid any references that would create any plagiarism.  It’s the way it works, with 60% of what you read today being produced in this fashion.  </p><p><a href="http://ducknetweb.blogspot.com/2015/04/news-rigging-has-arrived-astroturf-and.html"><strong>News rigging Has Arrived! Astroturf and Manipulation of Media Messages-TED Video About “The Fake Grass Roots” Of Big Pharma and Other Campaigns That Fool and Fool Again…</strong></a><p>Coming back around to the PBM machines, these are all automated processed and you can’t see what’s really going on and it’s hard to make changes as they keep adding more layers of hidden computer code and then create a story that will dupe you into thinking that some new algorithmic processes are going to save the day for consumers, and that’s not true, the machines are there to create more profits, not a better world for us with getting our medications we need, they have a captive audience and they know it.  If thing were really working the way they said they were, we wouldn’t have news stories and legal cases like this. You take the receipts, the cost as it’s been done many times on what you pay for your prescriptions, and you end up with the same thing, algorithms that lie to you and a big media service today that supports the algorithms that lie and cheat.  It’s in your face and you can choose to look at reality or go off into a little virtual world where you convince yourself that this is just not happening, which many people do and then wonder why things are not getting any better. <p><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html"><strong>Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</strong></a><p>It’s what I call a “One Trick Algo” world out there for consumers and the PBM business clearly leads the way in all of this with trickery used with computer code to make you think this is not the case.  It’s all about selling, mining and scoring your data to rapidly increase the rate of inequality in the US and if you think that putting another layer top will fix things, you’re back in that virtual fantasy world as you can’t keep layering computer code and algorithms on top of bad models and expect anything to change, it will only get worse, more complex and that benefits corporate America when consumers have no clue about understanding the systems we are forced to deal with today, and you are told “just keep clicking” for those miracle fixes, which of course do not exist.<p><a href="http://ducknetweb.blogspot.com/2017/04/one-trick-algo-world-needs-to-be.html"><strong>“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control</strong></a><p>So there’s coupons out there for saving on your prescriptions, but did you know it’s just another pharmacy benefit manager financing the coupon?  Why do they do it?  They do it for money and data.  So as an example if your PBM is Express Scripts let’s say and you have a coupon from one of those discount card deals that will give you a better price, well it’s probably OptumRX (a wholly owned subsidiary of United Healthcare) that gives you the discount, so you’re still in the PBM game, just not the one that comes with your insurance plan to get your meds.  <p>These coupons too all have what is called a “bin” number on them just like your insurance plan has and you can easily do a “bin” number search on the internet to see who’s financing the discount of your prescription.  Drug stores have to pay a fee for the privilege of filling your prescription when a PBM card or discount is used and it’s called a DIR fee, and these get big as they do not all occur at the time of your transaction either.  When you ask for a “cash” discount from an independent pharmacy the drug store gets to avoid this fee and can keep more of the revenue and not have to give it to the PBM.  The DIR fees are yet another profit producing algorithmic machine of their own accord.  Recently it was discovered that Caremark was charging their own CVS drug stores a much smaller fee than what was being levied on other drug stores where Caremark is the patient’s PBM, so this gets very involved with quants and analysts figuring how much profit they can make with these fees.  Recently it was reported that the auditors at Publix Warehouse asked about the $25 Million<img align="right" height="208" src="http://lh3.googleusercontent.com/-XHSvyCC6Ly0/Vi7i2iz25hI/AAAAAAABMkY/pP9kI46N7qE/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline;" width="182"> Dollar DIR fees they had to pay, they didn’t know what they were and that’s a big charge so even the big corporations are getting screwed by the PBMs with these fees just to be able to fill your prescription.  What a big profit making algorithmic machine, is it not?<p>So if you have one of those cards, the one getting the big profits are the company names attached to that “bin” number folks.  A lot of pharmacists if you give them the chance will match that price or even give you a better price with cash, as both you and the pharmacist win that way versus having the PBM monster algorithms charging in to get their cut.  Now we have Cigna wanting to buy Express Scripts so they can be liked United Healthcare and keep all that money, but there’s only one problem with Cigna being late to the dance here and that’s the fact that Cigna had a 10 year PBM agreement with PBM Catamaran which was bought by OptumRX (UNH) and there’s 5 years left, so no Express Scripts for those insured by Cigna, you have 5 more years of OptumRX unless they cut some kind of a deal and pay United Healthcare a boat load of money.  Right now Cigna needs a bond sale to be able to buy Express Scripts as they don’t have enough money, so when’s that going to take place?  I wrote this article back in 2015 when OptumRX bought Catamaran and few folks seem to be aware of this as they are too busy with their little virtual worlds of Facebook Follies and playing games I think. <p><a href="http://ducknetweb.blogspot.com/2015/10/if-you-are-insured-by-cigna-guess-what.html"><strong>If You Are Insured by Cigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare</strong></a><p><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html"><strong>United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</strong></a></p><p>Actually Express Scripts uses a lot of OptumRX algorithms already and has since 2010 with their bogus<img align="right" src="http://lh3.googleusercontent.com/-WTU_WavuGLg/VYjYaFce1MI/AAAAAAABMZA/DCNNtafnZm8/image%25255B8%25255D.png?imgmax=800" style="float: right; display: inline;"> black box scoring metrics, so yeah they’re already connected at the algorithms you could say.  <p><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html"><strong>Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On Ingenix Algorithms–We Want the Revenue Please Don’t Stop</strong></a></p><p>And here it is a few years later, revisited to see what kind of a bogus data selling/mining business Express Scripts created with those Ingenix (Optum) algorithms, quite the deal when you are scored on bogus metrics every time you fill a prescription.  Are you a man seeing a female MD, whoops that’s bad and do you have kids at home, that’s bad too as they will distract you from taking your meds.  These companies get away with this crap and sell those scores to insurers right and left.  So the choice is yours to start reading up and not being so stupid and speaking out and realize it’s an algorithmic computer code service that is running all of this. <p><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html"><strong>Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</strong></a></p><p>Did you know FICO buys all this scoring data from PBMs and sells it too?  Sure they want to cash in and mix t<img align="right" height="282" src="http://lh3.googleusercontent.com/-U0fHNHM3Vvo/VYjYc7peUgI/AAAAAAABMZI/N5v7HrnJd2c/image%25255B3%25255D.png?imgmax=800" style="float: right; display: inline;" width="340">his crap in with your credit scores!  Please get angry about this and start speaking up as the well greased algorithmic machines are taking over your meds every way they can.  Big pharma buys these scores too and if they can show that folks aren’t really taking their meds with a bunch of bogus stats, it helps them keep the prices high with their political campaigns for profit as they come back with arguments that patients are not taking their meds so why should they offer them for less!   Look at the image from Express Scripts, they want to make the patients the problem!  Non-adherence is not a disease to be cured, it’s the price of the drugs that adds to people not taking their drugs, wake up to the scam for bigger profits.  <p><a href="http://ducknetweb.blogspot.com/2014/06/fico-medication-adherence-scoring.html"><strong>FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited</strong></a></p><p><strong>It’s pretty wild is it not that Express Scripts decided to turn medication adherence into a disease!  It’s not a disease at all.</strong>  They want you to think of it like you have cancer, diabetes, etc.  Beware of PBM marketing for profit.  <p>Be aware too of the next step of the PBM algorithms for profit, connecting coupons to your medical records.  This is promoted to doctors to provide you with an e-coupon that goes directly to the pharmacy in lieu of using your PBM discount.  When this is done electronically, you cannot ask for a cash discount from the drug store as the price is locked in and the drug store is electronically stuck with the DIR fee to pay that I discussed above.  If you are offered one of these, have the doctor print it out and give the drug store a chance to match it with a cash discount instead of sticking it to the drug store.  See how these algorithms for profit work and you had no idea at all.  It’s PBM wars you could say as if you don’t use your PBM for your script, or you don’t have one, by using a coupon, a DIR fee is created for the drug store to pay down the road and cha ching, cha ching they make some money. <img align="right" src="https://lh3.googleusercontent.com/-3vUPXlYry8E/WUtNkuod6xI/AAAAAAABM5U/RBTZvIgihuwzV9mJkE-v1WQA66bHnFg4wCHMYCw/image_thumb%255B5%255D?imgmax=800" style="float: right; display: inline;"> <strong>PBMs  want no prescription filled without a PBM getting a DIR fee attached in the overall performance standards levied on the pharmacy. </strong><p><a href="http://ducknetweb.blogspot.com/2017/06/pharmacy-benefit-managers-invade.html"><strong>Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX</strong></a><p>Actually if you pay cash the PBMs come knocking at the door of the drug stores in time as well if they can’t track a credit card transaction or one of these coupon things, along with any other data supporting a purchase and you’ll be labeled a non compliant outlier if you use cash as well.  Get a load of that as the pharmacists at the drug stores get presented with lists of patients who are not compliant, only because they pay cash.  See how these black box analytics are really bogus!  PBMs are right in there pushing the war on cash.  Too many cash clients make the drug store look bad, which is ridiculous!  <p><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html"><strong>Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</strong></a><p>I have quite a few more posts in the archives of this blog that explain a lot of this as well, read them and learn up as when you hear laws and rules are being created to control the costs of medications today, just laugh like I do at those attempts as they are fruitless and Congress is way too stupid to understand how the well greased PBM algorithmic machines work, as you can’t change the machines with verbiage and expect any changed outcome, corporate America just codes around the verbiage and cheats if they want as the code and algorithms are all locked up in black boxes which nobody except the PBM has access to, so as long as they can tell a story that their code is complaint with verbiage, the nightmare lives on and nothing gets changed and they’ll keep telling you to go hang out in your little virtual worlds of the Facebook Follies and the likes to speak out.  Nobody listens to any of that anymore as well, it’s just a place to vent and you get trapped in their well greased algorithmic machines as well.  Here’s a big part of the problem. </p><p><a href="http://ducknetweb.blogspot.com/2015/06/virtual-world-values-and-real-world-we.html"><strong>Virtual World Values and The Real World, We Have A Big Problem: People Can’t Tell the Difference Anymore as Perceptual Madness Grows to Further Accelerate Inequality…</strong></a></p><p><a href="http://ducknetweb.blogspot.com/2015/05/privacy-duping-of-america-intangible.html"><strong>Privacy Duping of America-The Intangible Threat Model Has Changed Significantly-Companies Hide The Code On the Web, $180 Billion Dollar A Year Business, Welcome to The Duperville World of Inequality..</strong></a></p><p>So in closing I hope helped make the case and explained a bit more about the well greased PBM algorithmic machines that are in control out there, and the only way to do anything is to dump some of these black boxes and furthermore get to see their code that’s patented and running everything.  Until something is done is, no laws, rules, etc. will have much impact, they just call in their quants and code around it.  You can hear more of that from a presentation I did a few months ago where I spoke and spelled a lot of this out at a big doctor convention.  Here’s a spoiler screen to the right…how do you like that patent?  Time to wake up dupes and speak up. BD<p><strong><a href="http://ducknetweb.blogspot.com/2017/11/algorithms-scoring-metrics-privacy-and.html">Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel</a></strong>

Pharmacy Benefit Managers Are Not Much More Than “Complex Well-Greased Algorithmic Human Scoring Machines” That Deny or Allow Access To Drugs To Create/Substantiate Big Corporate Profits

So let’s get down to what’s really happening here.  Once upon a time the PBM models were a different type of creature but as time moved on t...

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Optum/United Healthcare Quietly Sold Optum Hospice to Compassus in December of 2016-And Compassus Is Now Contracted Under Optum Services to Manage the Facilities, Services and Provide the OptumCare Doctors

<p>Optum certainly kept this very quiet when they sold their hospice facilities to Compassus and I don’t think they even told their own investors.   I could not locate any SEC 10k filings or even a Form D from a search I did and this sale took place a year ago.   Optum is not not out of this business though, they want to manage it instead, just as they manage surgeons and physicians with <a href="http://scasurgery.com/about-us/overview-history/">Surgical Care Affiliates</a> and <a href="https://professionals.optumcare.com/engagement/ways-engage.html">OptumCare doctors.</a>  The worst nightmare for those in hospice has come true, the thought of Optum utilization managers prowling around Compassus Hospice facilities as they intend now to use Optum Hospice Services to manage them.  The old webpage of Optum Hospice is now gone as well, and has been replaced with <a href="https://www.optumcare.com/services/advanced-care/hospice-care.html">a page featuring “hospice services”.</a>  <p><strong>Hospice care by the algorithms is what we are looking at here</strong> with even <strong>more undue and not proven analytical scoring of patients taking place at their last days of their lives.</strong>  I think the screen from this Compasssus PowerPoint presentation on the revenue growth here tells the story of what this company’s (Compassus) goals are revenue and not patient care being the first priority.  You can see the other hospice services Compassus has acquired as well as Optum.  Their goal here is to create a model (made up of algorithmic functions) to design care for those patients in hospice services.  One might also guess that OptumRX will be the PBM of choice for these hospice facilities as well, all part of United Healthcare.  <p><a href="https://lh3.googleusercontent.com/-LSWkyVfbQJs/WkRo6lqLWII/AAAAAAABNLs/IMG1_i-ODDQ0DaBzL6WSN_SaBCrhGYWBwCHMYCw/s1600-h/clip_image001%255B5%255D"><img alt="clip_image001" border="0" height="375" src="https://lh3.googleusercontent.com/-SDAuZcM7UR8/WkRo7LyDOTI/AAAAAAABNLw/LrsMIKAW_sgg5aGPcdTXp8BoVb06Ki8OACHMYCw/clip_image001_thumb%255B2%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; display: inline; background-image: none;" title="clip_image001" width="484"></a><p>And here’s the management plan as you can see below with touting the Optum Partnership.  Compassus is owned by private equity firms,  Formation Capital and Audax Private Equity.  Private equity firms are currently draining the money out of nursing homes too, look at Kindred and HCR Manor (the one that Carlyle just walked away from as they couldn’t bleed it anymore).   With Kindred being purchased by Humana and two private equity firms, we can just assume that Humana is in there to make money from their Humana PBM from the drugs prescribed with the hospice services and the 2 private equity firms might be looking for any assets they can find to drain to line their own pockets, so that future there for patients and their care seems to look somewhat dim.  The real estate assets seem like they are always the first to be sold off, to leave the hospice and nursing home locations as “renters” for their facilities with high monthly payments, sometimes to another private equity firm held company that owns the properties.  <p><a href="https://lh3.googleusercontent.com/-96iGJxvNg3k/WkRo7tDBq1I/AAAAAAABNL0/6l4tab1BWvQO5UUAD2oUoRshBd-O2OubACHMYCw/s1600-h/clip_image002%255B5%255D"><img alt="clip_image002" border="0" height="368" src="https://lh3.googleusercontent.com/-ot6vXGW653M/WkRo8F_lVWI/AAAAAAABNL4/h2LNHKE58xY08HNQr91HmUPTzjNQzYqdACHMYCw/clip_image002_thumb%255B2%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; display: inline; background-image: none;" title="clip_image002" width="493"></a><p>So after private equity has finished bleeding  US retailers to the point of bankruptcy, is this is the next level, nursing homes and hospice services for the next asset drain?  It certainly is beginning to look like it.  Unlike the retailer asset bleed, this time we are dealing with people’s lives and a big potential for patient endangerment, all for the sakes of the private equity companies being able to put more money in their own pockets.<p>Again, one has to wonder why this was kept secret and given no press at all, and it’s only now that the facilities themselves are making the name changes that this has come to light.  I would search out a non profit for a family member for sure versus this hospice for profit group here, as that’s what hospice should be, for the patient and not come with a profit portfolio at the starting gate.  BD

Optum/United Healthcare Quietly Sold Optum Hospice to Compassus in December of 2016-And Compassus Is Now Contracted Under Optum Services to Manage the Facilities, Services and Provide the OptumCare Doctors

Optum certainly kept this very quiet when they sold their hospice facilities to Compassus and I don’t think they even told their own investo...

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Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

<p>This is a video of a recent presentation I did at the 74th Annual AAPS (American Association of Physicians and Surgeons) meeting.  I don’t do too much blogging anymore as I don’t want to be confused with all the “junk” news out there but thought this is worth a look and listen for all.</p><p>The presentation was initially intended for a physician crowd, but after I thought about it, consumers can learn a lot from this as well.  We have too many folks today <a href="http://ducknetweb.blogspot.com/2015/06/virtual-world-values-and-real-world-we.html">choosing “virtual” values and getting lost in the real world and don’t realize</a> what goes on behind the scenes, and it’s a lot, things you can’t see rising from corporate America to gain control of us lesser valued serfs it seems.<a href="https://lh3.googleusercontent.com/-x9TT-P6Qjsc/WhHuVDVWncI/AAAAAAABM6k/xN1ufLdHrMM8gaJiMxDf4aNpcDKifKFoACHMYCw/s1600-h/Optum_moneyball%255B4%255D"><img align="right" alt="Optum_moneyball" border="0" height="149" src="https://lh3.googleusercontent.com/-NMTC07Amu2I/WhHuVoIroiI/AAAAAAABM6o/74SyRudsU7IGGN1PBCMVEbp4DoYGFY9sACHMYCw/Optum_moneyball_thumb%255B2%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; float: right; display: inline; background-image: none;" title="Optum_moneyball" width="207"></a></p><p>Every direction you turn today, somebody is <a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html">mining up some behavior data and scoring you today, so we have so many scores</a>, and many of them secret, who knows what value some big corporation or government is putting on our head today?  I’ve been writing about this for years and unfortunately we have gone beyond just good production software that helps us in life and in doing our jobs into a somewhat digital caste system.  I used to write software and this is my attempt here to let the average consumer know more about what’s really taking place out there.  I thought the Obama administration was getting way too virtual, but it seems the new Trump administration is just as bad with not seeing the real world and embracing virtual world values as well, so I guess it doesn’t matter which person or party is in control out there today, <strong>they don’t like the ugly real world </strong>and keep pushing virtual values on all of us to keep consumers in the dark.</p><p>I call it a <a href="http://ducknetweb.blogspot.com/2017/04/one-trick-algo-world-needs-to-be.html">“One Trick Algo” world</a> and that’s what you’re getting too often out there today, some algorithms and computer code, written by corporate America to profit that tricks you into things you would rather not do if you knew the whole story.  I call this <a href="http://ducknetweb.blogspot.com/2015/06/operation-perception-deception-into.html">“Operation Perception Deception”,</a> which was a post I wrote back in 2015 and sadly it’s getting bigger every day.  So take a look and see what’s going on behind the scenes in healthcare, and don’t deceive yourself too badly with virtual values as people can’t seem to be able to tell the difference anymore.  BD</p><p><iframe width="560" height="315" src="https://www.youtube.com/embed/vKBMXQXWvvs?rel=0" frameborder="0" allowfullscreen=""></iframe></p>

Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

This is a video of a recent presentation I did at the 74th Annual AAPS (American Association of Physicians and Surgeons) meeting.  I don’t d...

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Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX

<p>This should not really come as a big surprise as what hasn’t the pharmacy benefit managment business touched?  So what is <a href="http://www.optimizerx.com/partners/">OptimizeRX</a>?  Most have probably not heard of this software but it is a connect to EMRs that will send your prescription right to the pharmacy.  Oh, now you say, well <a href="https://lh3.googleusercontent.com/-Z88dYoMA-lE/WUtNjFKWRaI/AAAAAAABM5I/DnLHsZ4f5Kc_UhJvDVujRB362nFI4QcGQCHMYCw/s1600-h/image%255B26%255D"><img align="right" alt="image" border="0" height="239" src="https://lh3.googleusercontent.com/-6all7ydUdJk/WUtNjjNjIqI/AAAAAAABM5M/AsgzJfXMhSUXqgAhw8vBHIPiyG3XG91mQCHMYCw/image_thumb%255B16%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; float: right; display: inline; background-image: none;" title="image" width="425"></a>the PBMs do that and they do but what they have been missing is a way to collect data on patients who are not using their PBM prescription card or those who do not have one.  It’s all about getting more data about you to “score” and of course sell those scores to insurers and other interested parties.  Once the pharmacy has the transaction, it does not fall under HIPAA rules as it’s a prescription, linked to an EMR to provide a transaction.  As we all know, your medications in an EHR are protected but again, I’ll repeat this for those who still think HIPAA is covered at the pharmacy, it is not.  It’s been a sore spot for years with privacy.</p><p>If your doctor is using one of the medical records systems in the image at the right, they are partners with OptimizerRX.  From the website:</p><p><em>“OptimizeRx® has developed an extensive network of EHR and eRx platform partners*, as well as partnerships with media and creative agencies, making it easy for marketers to achieve excellent reach with their HCP customers. View the partner network information below for details. EHR and eRx partners benefit from the partnership by adding OptimizeRx’s suite of services seamlessly into their platforms, providing relevant patient support, patient education and other services that are welcomed by their HCP customers. Integrating OptimizeRx into an EHR or eRx platform is simple and easy, and can usually be completed in less than eight hours!”</em></p><a href="https://lh3.googleusercontent.com/-_fvfQvtrHq8/WUtNkCM3FNI/AAAAAAABM5Q/IpzZdpjtIMI_oogPqj3C48GwrK2kTy9mACHMYCw/s1600-h/image%255B9%255D"><img align="right" alt="image" height="234" src="https://lh3.googleusercontent.com/-3vUPXlYry8E/WUtNkuod6xI/AAAAAAABM5U/RBTZvIgihuwzV9mJkE-v1WQA66bHnFg4wCHMYCw/image_thumb%255B5%255D?imgmax=800" style="float: right; display: inline;" title="image" width="485"><br></a><p>Did you catch this, it’s about marketing and at least they say as much.  When you look at the executive page, you’ll find most of these folks came from the pharmaceutical business.  Here’s another screenshot to “auto send” the prescription along with the RX pricing information direct to a pharmacy.  What this means is the price is locked in and a pharmacist has to honor that as it’s aready in the data base, precluding the availability to offer a cheaper discount.  Certainly it appears to make it easier for the patient, but is it the best price?  We don’t know.  In addition, the providers can print a coupon for those who say “no, don’t do that’.  </p><p>This RX discount card also can text and email you.  So there you go, it’s all about the data that drug companies and PBMs want on folks not using their PBM discounts.  If you let the MD do the auto send, you’re stuck with that price and can’t compare.  There’s this little item I wrote about a while back about medication adherence prediction compliance and if you are not aware of this game, read the link below and this has been around for a while and was originally created with Ingenix (OptumRX now) algorithms that goes back to 2010 when Express Scripts put out a press release on how they were going to score you, and they all do that now.  This is some real flawed information too as the 300 metrics used have zero to do with taking meds.  You get a bad nick for example if you are a male seeing a female MD and so on.  This is not science, it’s behavior bullshit that at best may show trending.  So this OptimizerRX is software to use the EMR to drag in the so called “Outliers” who pay cash and are not using a PBM discount.  Part of the job of a pharmacist today is to identify their outliers and fix them, but if the data is flawed and they pay cash, it’s just a bunch of flawed data.<a href="https://lh3.googleusercontent.com/-yF_FY0XQgcw/WUtNk1SMpGI/AAAAAAABM5Y/L9MUzQKDY9YARDJsGOc1bhdo3gGyDrX4wCHMYCw/s1600-h/image%255B14%255D"><img align="right" alt="image" border="0" height="64" src="https://lh3.googleusercontent.com/-L0HcjNXeAH4/WUtNlFYX6rI/AAAAAAABM5c/pq3oOHbb70MF6VuyEhQghcUGmK3hkC8ggCHMYCw/image_thumb%255B8%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; float: right; display: inline; background-image: none;" title="image" width="269"></a></p><p><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html"><font size="2">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “outliers, Pharmacists Required to Fix outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</font></a><p><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html"><font size="2">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</font></a><p>So now we have talked about OptimizeRX (which just happens to sound a lot like OptumRX) let’s move to the next step here and talk about the discount card.  Read the press release below, OptimizeRX has a partner called SingleCare, which actually resembles the HealthAllies company that Andy Slavitt and Senator’s Warren’s daughter sold to United Healthcare, except this one is free.  SingleCare includes other available discounts, a few of them but hey well all know it’s about getting the pharma PBM money to support the entire project, not a 20% discount at a gym or free teeth cleaning. <h3><a href="https://globenewswire.com/news-release/2017/04/05/954708/0/en/OptimizeRx-Partners-Exclusively-with-SingleCare-to-Bring-Patient-Savings-and-Price-Transparency-to-Healthcare-Providers-at-the-Point-of-Prescribe.html"><font size="2">OptimizeRx Partners Exclusively with SingleCare to Bring Patient Savings and Price Transparency to Healthcare Providers at the Point of Prescribe</font></a></h3><p>SingleCare started out much like <a href="https://scriptrelief.com/">Script Relief</a> (another RX discount card that markets under a ton of names run by Loeb Enterprises in New York) to get some users of the discount so they could collect money from the PBM.  All the Script Relief cards make their money back from OptumRX on the fees and other charges and they pay independent sales people $10 a hit for every patient who activates a card.  Script Relief was originally connected with Catatmaran, which was bought by OptumRX (United Healthcare) and played a big role with Cigna getting sanctioned by CMS for a long time from selling Medicare D policies.  Here’s a couple archived links on tha topic and once the OptumRx purchased Catamaran, who was the in-house PBM for Cigna, all insured had a new PBM called United Healthcare (OptumRX) PBM.</p><p><a href="http://ducknetweb.blogspot.com/2015/07/united-healthcare-having-big-bond-sale.html"><font size="2">United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion</font></a></p><p><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html"><font size="2">United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</font></a></p><p>So what kind of executives does SingleCare employ?  Well you could probably guess this one easy<a href="https://lh3.googleusercontent.com/-7h3R-J1_DyQ/WUtNlr6rRHI/AAAAAAABM5g/RQZtgW-mYjYu32boLHRTtrJZ-2lqret_QCHMYCw/s1600-h/image%255B20%255D"><img align="right" alt="image" border="0" height="188" src="https://lh3.googleusercontent.com/-mpsJZc1Lnuo/WUtNlzBledI/AAAAAAABM5k/Rbb377ZEkVg7u2C3IPpF0-Yu-pj3WoBaACHMYCw/image_thumb%255B12%255D?imgmax=800" style="border: 0px currentcolor; border-image: none; float: right; display: inline; background-image: none;" title="image" width="485"></a> enough, former United Healthcare and big time former Catamaran executives.  <a href="https://www.singlecare.com/about-us">Check it out.</a>  In addition the company also says it will bill patients who use their discounted MD, dental cleaning, etc. services.  Yikes as a patient, I would much rather pay the doctor direct and not have some big corporate conglomerate chasing me who also wants my data to score and sell.  Many MDs have already figured out how these virtual credit cards hit them up for big fees anyway, so they keep part of that money for giving you a discount.</p><p><a href="http://ducknetweb.blogspot.com/2014/06/health-plans-and-claim-clearinghouses.html"><font size="2">Health Plans and Claim Clearinghouses With Virtual Credit Cards-Racking Up Additional Fees From Doctors</font></a><p>So what PBM do you think is supporting this?  My guess would be OptumRX but you can’t find that stated anywhere, but hey put two and two together.  So if you use the card, you are added to a PBM data base with data to score and sell and again, we think it’s OptumRX.  If you noticed above, Allscripts is one of the partners and is it not a coincidence that all OptumCare MDs are required to use Allscripts?  Here’s more on that topic along with a picture I snapped of one of their OptumCare owned MDs in the OC.  Don’t forget too that all the Surgical Care Affiliate outpatient surgery facilities are now owned and will be run by OptumCare, so I might guess Allscripts will be over there too, or OptimizeRX will sign up more EHRs to bring in the SingleCare discount card over there too.  <p><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html"><font size="2">OptumCare Doctors to Get allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</font></a><p>We also have this action going on relative to OptumRX and Catamaran with lawsuits being filed over the price of prescriptions when a cash offering is less expensive than what the PBM is offering.<p><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html"><font size="2">Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</font></a><p><a href="http://ducknetweb.blogspot.com/2016/11/pharmaceutical-wholesalers-inc-file.html"><font size="2">Pharmaceutical Wholesalers Inc. File Legal Complaint Against OptumRx “Aligning Its Interests” with the Big Three Drug Distributors in US, Thus Acting as an Agent of the Government With Accreditation Processes</font></a><p>Bottom line here is to get the algorithms connected to the EHRs now and get that price locked in and get the data from the folks who are not using a PBM price. <p>Also the MedExpress urgent care locations are also connected to, guess who, OptumRX and you might be seeing those SingleCare RX discount cards used there as well.  United Healthcare also <a href="http://ducknetweb.blogspot.com/2014/02/allscripts-ends-up-with-loss-for-2013.html">has another service</a> they market where they want to be the EHR integrator for Allscripts and other medical record companies.<p><a href="http://ducknetweb.blogspot.com/2015/04/optum-united-healthcare-buys-medexpress.html"><font size="2">Optum (United Healthcare) Buys MedExpress Urgent Care Business- 141 Full Service Clinics In 11 States–Company Advertises They Are In the Market to Buy Your MD Practice, As A “Too Big To Fail Insurer” Moves Forward With More Acquisitions</font></a><p><a href="http://ducknetweb.blogspot.com/2013/11/united-healthcare-optum-insight.html"><font size="2">United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond</font></a><p>How convenient to be an EHR integrator and get that OptimizeRX connected in there to the medical records to promote the SingleCare discounts and collect data on folks who are not using their PBM program or are paying cash.  By the way too, Optum is also now doing the billing for Quest Labs in case you missed that one.  Optum does the billing of course for their very close partner, the Mayo clinic, who’s CEO just took a board seat with Merck Pharmaceutical.  Are you seeing some kind of a pattern yet, maybe?  Of course if you are insured by United, you have been told to go to LabCorp for years for actual tests. <p><strong><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html"><font size="2">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</font></a></strong><p>The prescription discount game is heating up out there and <a href="https://insiderx.com/"><font size="2">Express Scripts doesn’t want to be left</font></a> out as they too now have an RX discount card, called Inside RX which is a partnership with GoodRX, as they too didn’t want to get left out of the lucrative “fee” business here.  Sounds like <a href="https://lh3.googleusercontent.com/-rceme3WvQ18/WUtNmfQPLgI/AAAAAAABM5o/uYs-qFfPYSgEoycHIw4Le9Yr2GgR9IjDQCHMYCw/s1600-h/image%255B25%255D"><img align="right" alt="image" border="0" height="118" src="https://lh3.googleusercontent.com/-V_gGVhSx4jk/WUtNmmFy6zI/AAAAAAABM5s/201iybyxGIoJwXTD-mM0k_VUFPojcxzOACHMYCw/image_thumb%255B15%255D?imgmax=800" style="border-image: none; float: right; display: inline; background-image: none;" title="image" width="207"></a>OptumRX was cutting them out of some of the money mabye, so off to Express Scripts they went.  </p><p>Here’s a post I did a while back with some good videos from actual independent pharmacists that tell you the story on how the RX discount cards work and how a lot of time they might still be able to give you a better cash price that doesn’t support all this markeing.</p><p><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html"><font size="2">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</font></a><p>So backon topic here with SingleCare benefits, be aware of what’s going on with the algorithms of the PBMs as they are now invading medical records to get that script and and that data about you.  I would be very careful about wanting to use any of the texting and email services they offer as they collect and monitor everything today and will “score” your behavior with their services to toss some kind of risk in a profile about you!  Recently<font size="2">, </font><a href="http://www.bizjournals.com/twincities/news/2017/06/16/optums-vc-arm-backs-startup-that-mines-smartphone.html"><font size="2">VC arm of Optum/United Healthcare invested money in another cesspool Silicon Valley risk assessment company</font></a><font size="2">, </font>Mindstrong to monitor people with cell phone behavior and when they get done scoring all that type of data, we’ll all be at risk for mental health issues if we “hesitate” on responding to text messages.<p>So be aware now as the PBMs have infiltrated medical records and stalking you there, with going beyond just regular PBM plans, they want to get data on everyone who pays cash to “score” and sell a data profile about you and your behavior.  Once you get locked with with your doctor doing an automatic send to the pharmacy, the pharmacist may not be able to offer you a less expensive price if they have one to offer on your medication.  BD 

Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX

This should not really come as a big surprise as what hasn’t the pharmacy benefit managment business touched?  So what is OptimizeRX ?  Most...

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DOJ Enters WhistleBlower Law Suit Against United Healthcare–Risk Fiddling for Profit, A Walk Back Down Ingenix Memory Lane Again

<p>Here we go again, back to those Ingenix algorithms and business models, getting a rerun of sorts of what occurred in 2011.  In 2011 there was one main lawsuit from the AMA along with many others that were filed (some being still settled) over using formulas that short changed doctors and patients on out of network chargees.  In addition, all other insurers who licensed and used the formulas were also drug<a href="https://lh3.googleusercontent.com/-8NzMOjjBagg/WK5g1-wSfAI/AAAAAAABM3s/AOVqANS-jQE/s1600-h/image%25255B4%25255D.png"><img align="right" alt="image" border="0" height="237" src="https://lh3.googleusercontent.com/-biRchvnIWtQ/WK5g2ktWtlI/AAAAAAABM3w/TCmRA3P5nMY/image_thumb%25255B2%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="309"></a> into court for settlements.  This was a big deal and now we have another lawsuit with again, other insurers being named for using the formulas of Ingenix once again.  Here’s a case that has not settled yet as an example and one that just recently settled.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/cigna-legal-case-with-ingenix-flawed.html">Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/08/ingenix-optum-united-healthcare.html">Ingenix (Optum-United Healthcare) Lawsuits Still Bouncing Around Out There–One Recently Settled in New Jersey With Horizon Blue Cross Blue Shield That Was Still Using the Flawed and Corrupt Data Base for Out of Network Payment Calculations</a></h5> <p>A couple years ago Medicare said they were going to rerun the Medicare risk assessment scores, so there was no secret as to what was going to occur with an audit. <h5><a href="http://ducknetweb.blogspot.com/2015/03/cms-to-rerun-medicare-advantage-risk.html">CMS to Rerun the Medicare Advantage Risk Scores–Dating Back to 2008 To Catch the Automated Risk Fiddlers of Said Insurer Fraud Amounting to Around $70 Billion–Be Ready For It…</a></h5> <p>There are other lawsuits on the books that have not settled yet in other areas, like this one with mental health that could go to a class action suit too. <h5><a href="http://ducknetweb.blogspot.com/2013/03/class-action-lawsuit-filed-against.html">Class Action Lawsuit Filed Against UnitedHealthGroup and Their Various Subsidiaries There Of Relative to Mental Health Claim Denials & Violation of Parity Laws</a></h5> <p>Here’s a back link to the big settlement by the AMA.  Again this is only one of many and at the time I was writing a series of blog posts called “The Attack of the Killer Algorithms and this was chapter 19.  </p> <h5><a href="http://ducknetweb.blogspot.com/2012/02/ama-announces-doctors-and-patients-can.html">AMA Announces Doctors And Patients Can Expect To See the UnitedHealthCare/IngenixClass Action Settlement Checks In the Mail Soon - Out of Network Short Payments–Attack of </a></h5> <h5><a href="http://ducknetweb.blogspot.com/2012/02/ama-announces-doctors-and-patients-can.html">the Killer Algorithms Chapter 19</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2011/04/unitedhealthcare-erisa-class-action.html">UnitedHealthcare ERISA Class Action Lawsuit Expanded to Include DME and Ambulatory Surgical Center Providers</a></h5> <p>If you missed this along the way, things go so ugly with the Ingenix name, United Healthcare changed it to Optum, which you see all over the place today, as they are buying up broke doctor practices and urgent care centers like they are going out of style.  There’s 2 sides to United Healthcare, one that does insurance and the other Optum side that’s buying up and creating software was well as consuming and acquiring companies that have anything to do with doctors. <h5><a href="http://ducknetweb.blogspot.com/2011/04/unitedhealth-group-announced-re.html">UnitedHealth Group Announced Re-Branding of Business Units-Focus on “Optum”–Changes IngenixName to OptumInsight</a></h5> <p>So again with this new lawsuit, which was created from the efforts of a high ranking former United Healthcare executive, not just an employee, we are seeing the same process again, Ingenix algorithms and models followed to fiddle with risk scores, make patients look sicker and get more money from the government this time instead of doctors. <p>Express Scripts ended up at one point in time a while back buying the old United Healthcare pharmacy benefit business and acquired some software and algorithms in the process and in 2010 was bragging how they are going to predict if you will take your medications.  This flawed scoring still goes on today. <h5><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html">Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On IngenixAlgorithms–We Want the Revenue Please Don’t Stop</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>The entire <a href="http://constantinecannon.com/whistleblower/wp-content/uploads/sites/2/2017/02/U.S.-v.-UnitedHealth-Group-First-Amended-Complaint.pdf">lawsuit can be read here</a> and there’s quite a few pages to the pdf to read.  Benjamin Poehling was the former high ranking executive that filed the whistle blower lawsuit.  It’s kind of uncanny that Poehling came from Arthur Andersen, where the current CEO of United Healthcare worked as Anderson’s CFO and all the Enron issues were on his watch.  Enron lead to the end of the Arthur Andersen auditing firm due to fraud.  Here’s a few quotes from the suit… <hr> <p><em>“United’s senior management push relentlessly to increase United’s revenue from risk adjustment. Tellingly, UHMR has assigned risk adjustment to its Finance Department, not one of its clinical departments. (Relator was assigned to his job despite having no clinical background.) In 2010 and 2011, UHMR has implemented projects referred to as “remediation plans”, “focus area projects,” or “affordability agendas” to increase IOI.</em> <p><em>UHG engages in an aggressive and extensive effort to find a justification or pretext to submit risk adjustment claims for additional diagnoses—regardless of whether the patient had or was actually treated for the diagnosis in the relevant period by a qualifying provider. United’s program has some components that are broad-based, and others that target specific high value HCCs. As an overall goal, UHG attempts to reach each of its members at least once every two years through one of its programs designed to find additional risk adjustment claims. </em> <p><em>Ingenix conducts chart reviews on behalf of UHMR, UHCS, and commercial clients. In the retrospective chart review process, Ingenix identifies provider charts to review and arranges for the charts to be collected. It uses both internal coders and also contracts with external vendors to review and code the charts. 129. These vendors review charts using a blind review. In a blind review, the reviewer codes every <a href="https://lh3.googleusercontent.com/-f43KV0WYLek/WK5g3RYjExI/AAAAAAABM30/kiGdiLtsRK0/s1600-h/image%25255B9%25255D.png"><img align="right" alt="image" border="0" height="123" src="https://lh3.googleusercontent.com/-fBbsaLzUH1s/WK5g4KJEweI/AAAAAAABM34/geIdBViAYIA/image_thumb%25255B5%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="469"></a>condition he or she identifies from the chart without knowing what codes the provider identified from the chart previously. Thus, the reviewer works from the raw chart material and reaches independent conclusions.</em> <p><em><strong>Under the COI program, United pays providers approximately $100 for each diabetes patient they assess for diabetes complications, submit a supporting diagnosis via a claim, and submit a medical record with matching documentation. In addition, it pays $200 for each doctor that receives training on the COI program and diagnosis coding. Recently, the COI program has expanded to other conditions that United suspects are frequently undercoded, such as chronic kidney disease (“CKD”), and chronic pulmonary disease (“COPD”).</strong></em> <p><em>Relator knows that at least the following United executives know about some or all of the problems discussed herein, and have participated in the scheme to continue submitting fraudulent claims and to refuse to correct previously submitted false claims: Stephen Hemsley, UHG Chief Executive Officer; Gail Boudreaux, UHG Executive Vice President and CEO of United Healthcare; Larry Renfro, Optum CEO; Tom Paul, UHMR Chief Executive Officer; Cindy Polich, UHMR President; Lee Valenta, Ingenix’s former Chief Operating Officer (and current President of Ingenix’s Life Sciences Division); Jack Larsen, former CFO of PSMG (and current CEO of UHCS); Scott Theisen, UHMR Senior Vice President of Finance; Jeff Dumcum, Senior Vice President of Ingenix; and David Orbuch, PSMG Chief Compliance Officer.</em> <p><strong><u>And this….</u></strong> <p><em>“United’s refusal to correct errors in its risk adjustment claims is so extreme that it submits risk adjustment claims to CMS for diagnoses taken from claims that it itself refuses to pay as being fraudulent and/or abusive.</em> <p><em><strong>United developed “playbooks” containing ideas for increasing its risk scores.</strong> These playbooks are garnering top-level attention at the company while the myriad problems with United’s risk adjustment programs and processes go unresolved. 195. United conceals the one-way nature of its risk adjustment programs from CMS and even its investors. For example, United’s remediation plan for 2010 that sought to increase IOI by $800 million allocated $100 million to “Project 7.” Project 7 was United’s codeword for initiatives to increase risk adjustment payments. The company used a codeword (as opposed to “growth,” “enrollment,” or “claims”) because it did not want CMS or other investigatory government agencies to know it had a campaign to claim an additional $100 million through risk score increases.</em> <p><em>United customizes its kickbacks depending on the nature of its overall reimbursement arrangement with the provider group. The providers United chooses to pay additional amounts for increased risk scores are those that do not already have an incentive to upcode diagnoses. United uses three basic payment structures for its providers: (1) percent of premium capitated providers, which receive a percent of United’s CMS premiums for its patients; (2) “fixed” capitated providers, which receive PMPM payments from United that are not tied to United’s CMS premiums; and (3) feefor-service providers, which are paid based on the claims they submit to United.”</em> <hr> <p>If you made it through those paragraphs you can easily see how complex insurers have made medical billing for sure.  Once again we come back to the business models of Ingenix and some of the automation in the IRAD data base to work these claims.  Here’s another billing subsidiary United bought, again we’re talking coding and billing here. <h5><a href="http://ducknetweb.blogspot.com/2010/09/ingenix-wholly-owned-technology.html">Ingenix (Wholly Owned Technology Subsidiary of UnitedHealth to Acquire A-Life Coding Software/Services–Tons of Money and Profit With Coding Transactions and Algorithms - Subsidiary Watch</a></h5> <p>I talk too about the United/Optum incest at times too with HHS and CMS and here’s a blast from a few years ago…this was the beginning of pushing “population health” that all know the term and nobody really knows what it does half the time to even include vendors of the algorithmic processes.  This is where the government bought yet another United Healthcare model. </p> <h5><a href="http://ducknetweb.blogspot.com/2010/06/for-top-program-combines-prototype-from.html">"Reach for the Top" Program Combines Prototype from Ingenix (A Wholly Owned Subsidiary of United Healthcare) for Public/Private Community Health Data on HHS.Gov Site</a></h5> <p><strong>Simon Stevens, who is now running the NHS and worked at United Healthcare</strong> a few years ago had this to say…</p> <h5><a href="http://ducknetweb.blogspot.com/2009/05/united-health-care-says-cheaper.html">United Health Care Says Cheaper Efficient Doctors and Reducing Hospital Visits by the Elderly Would Help Reduce the Cost of Healthcare</a></h5> <p><strong>Former Acting director of CMS, Andy Slavitt claims Simon is a good friend of his and let’s not forget that Andy Slavitt was the CEO of Ingenix when a lot of this was going on.  Larry Renfro came in later from his executive position at AARP to run the Ingenix show.</strong>  </p> <p>United Healthcare sure seems to be lining up some big executives as well with last year hiring the former CEO of Stanford University Healthcare to work for United as a VP and recently in the UK, Optum hired Nick Seddon, who worked for David Cameron as his special healthcare adviser.  There’s a group in the UK that is also bringing attention to the fact that one company, United/Optum has been taking over way too much ground and is not leaving enough competition out there with other countries.  </p> <p>The entire suit takes a while to read but there’s a ton of detailed explanations as to what United and other insurers taking advantage of their consulting and billing services are accused of.  Again, do leopards change their spots?  Here’s another suit you might want to read about…it just does not stop when you have complex built algorithms that can spin around faster than you can take a deep breath to score and stick you with more risks than you ever dreamed of, all for the sake of making money from the government.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html">Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</a></h5> <p>Feel free to search this blog, there’s plenty of information like this written since 2008 on how companies cheat with computer code and algorithms…BD  </p> <p> <hr> </p> <p>United Healthcare, the largest provider of Medicare Advantage (MA plans) services, is being sued by the Department of Justice (DOJ) for fraud. To give you a sense of United Healthcare’s size consider that just their third quarter revenue was $46.3 billion, up 11.6 per cent from the same period a year earlier, and the bulk of the growth was billing services and data analysis for healthcare groups, which ws up 34 percent since the beginning of 2016.</p> <p>Medical charts, the primary source of diagnostic data were reviewed looking for incremental increases but not for errors that would decrease the risk adjustment.  New diagnostic codes were submitted, but an erroneous diagnosis was not deleted. On a two-way street, “they do not look both ways.” And these reviews were profitable, a $30 cost for chart review resulted in an average of $450 in additional payments. Ingenix sought to find additional diagnosis by using data analytics to identify practices, where chronic conditions were underreported based on population prevalences or where a new diagnosis was suggested by medications patients were receiving. Here the physician was contacted with patient assessment forms (PAFs) to consider these diagnoses for the patient. Physicians receive a small fee for reviewing these PAFs. Ingenix also developed initiatives designed to get patients to visit their doctors each year. But wait a minute, these programs encourage physicians to screen patient’s more carefully and to encourage annual checkups.</p> <p><a href="http://www.acsh.org/news/2017/02/21/department-justice-believes-united-healthcare-defrauding-medicare-10885" title="http://www.acsh.org/news/2017/02/21/department-justice-believes-united-healthcare-defrauding-medicare-10885">http://www.acsh.org/news/2017/02/21/department-justice-believes-united-healthcare-defrauding-medicare-10885</a></p>

DOJ Enters WhistleBlower Law Suit Against United Healthcare–Risk Fiddling for Profit, A Walk Back Down Ingenix Memory Lane Again

Here we go again, back to those Ingenix algorithms and business models, getting a rerun of sorts of what occurred in 2011.  In 2011 there wa...

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Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

<p>Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers.  Cigna provides the insurance benefits and then it’s pharmacy benefit manager, PBM OptumRX (biggest revenue sector subsidiary of United Healthcare) that runs all their formulas via the computer and tells the pharmacist what to charge you.  (Video at the break below-watch it!)</p> <h5><a href="http://ducknetweb.blogspot.com/2015/10/if-you-are-insured-by-cigna-guess-what.html">If You Are Insured byCigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare</a></h5> <p><strong>I call this “front running” the consumer at the prescription counter if you will,</strong> as that’s a term we hear used in stock trading all the time and it’s somewhat a very similar model with providing the drug stores advance information before you can even physically get there to ask for a cash price<a href="https://lh3.googleusercontent.com/-q-UPZgdLZ_c/WAPNzlK3WoI/AAAAAAABM1o/Ujtb-Zpcwds/s1600-h/Clawback-Cigna2.png"><img align="right" alt="Clawback-Cigna" border="0" height="154" src="https://lh3.googleusercontent.com/-QhPJyRFePt8/WAPN0Pb6L0I/AAAAAAABM1s/2x_J2Gm4Ij8/Clawback-Cigna_thumb.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Clawback-Cigna" width="244"></a> from the pharmacist.  Markets work the same way with dealing on advance information provided by their brokers and investment analysts, before their clients get a chance to see it.  <strong>Less than a month ago, United Healthcare received the same type of lawsuit for doing the same thing.</strong>  Below are a couple links with some videos that explain how this works in the words of the pharmacists.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/05/be-aware-of-prescription-claw-backs-as.html">Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve</a></h5> <p>In my own observations, Cigna is kind of living under the thumb of United Healthcare right now anyway and if I were them I would not be too happy having a competitor meddling in various areas of customer data that probably goes beyond prescriptions as United is the second largest healthcare data seller out there, behind IMS.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/cigna-launches-new-company-careallies.html">Cigna Launches New Company, CareAllies To Manage Patient Care, Doing Same Things as Does Optum</a></h5> <p>Actually the data selling algorithms provided mostly by United Healthcare/OptumInsights even goes beyond prescriptions and such algorithms were sold to a subsidiary of Quest Diagnostics called Exam One and they use the same formulas to score you and sell that data as well.  Also, in case you missed it, United Healthcare will be preparing your Quest Labs bill as well.  Another United Healthcare company, Optum 360, to which Dignity Healthcare is a partner will be doing their billing for them.  Over 2000 Quest employees were let loose and rehired under the Optum 360 name, and we kind of all know what that represents for the employees with reductions in pay, benefits, etc. in order to save money as that’s why they outsource.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</a></h5> <p>So how did this marriage occur?  <strong>United Healthcare under their “Optum” subsidiary bought a pharmacy benefit management company named Catamaran,</strong> who was the exclusive PBM (pharmacy benefit manager) for Cigna.  In addition, Catamaran was in a bit of hot water and partially responsible for getting Cigna sanctioned by CMS with denying drugs and access to care. <strong>Cigna was around 2 years into a 10 year contract with Catamaran </strong>and I assume that was a big lure for United Healthcare as with buying the PBM, they increased their OptumRX revenue by around 25% and there were about 8 years left on this agreement.  This sanction has been in place since January of this year (seems like a long time) and<strong> none other than former United Healthcare Executive CMS Andy Slavitt makes the call on when to allow Cigna to sell Medicare D policies again</strong>.  If you look at how this all came about and the competition with health insurers, it certainly gives the appearance that CMS Slavitt could very well be making sure his former employer, United Healthcare benefits.  </p> <p>Remember that<strong> HHS Secretary Burwell was able to provide pardons for Slavitt (so he could do his job, the reason) to discuss policy and healthcare business with United </strong>(to include the CEO) any time he wants, so who knows how often the two might get together for lunch and chew some healthcare policy and some fat.  Here’s the story on the sanctions levied against Cigna in January of this year.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-sanctions-cigna-no-more-selling-any.html">CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed</a></h5> <p>Cigna is also still saddled with yet another Ingenix lawsuit that has not completed and that goes back to the days when CMS Andy Slavitt as CEO of Ingenix was caught using algorithmic formulas to short pay doctors on out of network payments.  This was discovered by Andrew Cuomo and there were multiple class action lawsuits filed, including the big case from the AMA on the fraudulent activity in 2010.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/cigna-legal-case-with-ingenix-flawed.html">Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…</a></h5> <p><strong>United Healthcare had a $10.5 Billion dollar bond sale to acquire Catamaran PBM</strong> and wrap into OptumRX in record time with importing customers.  It was well stated all over the web outside of this blog that <strong>both companies were using “like” technologies</strong> so the process would be quick and easy.   Being a former developer and what I have seen over the years, there’s probably a good chance that Catamaran was licensing the old Ingenix or OptumInsights algorithms, as all the pharmacy benefit management software seems to come back to that being the tech or algorithms being used.  It’s not uncommon as for another example you have Cerner as  a reseller of Ingenix/Optum Revenue Cycling technologies with their medical records systems.  The link below gives you more information on the acquisiton of the Cigna Catamaran PBM by United Healthcare/Optum.  <h5><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html">United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</a></h5> <p>In addition last year United is getting into the workman’s comp area of pharmacy benefit management with buying Helios and the largest customer serviced by Helios is the US Post Office.  <h5><a href="http://ducknetweb.blogspot.com/2016/01/united-healthcare-buys-helios-workmans.html">United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses</a></h5> <p><a href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">The link at the bottom of this page</a> from the story reported (the source) has copies of the actual court documents filed against Cigna and United Healthcare and it’s called racketeering.  Be sure and check it out.  Most all the links in this post are prior posts from the Medical Quant that give you additional information relative to what’s going on.  Pharmacists are being told to not disclose the cash price unless you ask so be sure to ask. <p><strong>Pharmacists in this whole scheme are also required to use software to input data so PBMs can produce a  predictive secret score,</strong><a href="https://lh3.googleusercontent.com/-ygEDmyDQtho/WAPN0hN7ouI/AAAAAAABM1w/5I3HGXrY51Y/s1600-h/EQUIPP4.png"><img align="right" alt="EQUIPP" border="0" height="293" src="https://lh3.googleusercontent.com/-Yhjo_rObwDQ/WAPN01XTkCI/AAAAAAABM10/LliBi2CGen4/EQUIPP_thumb2.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="EQUIPP" width="288"></a> than can also be sold to predict if you will take your meds.  Read up on that one as well.  Most consumers have no clue they are being secretly scored with software that does produce flawed and bias data every time you fill a prescription.  One of the programs is called EQUIPP and recently Rite-Aid has rolled out this software to their drug stores and current users include Wal-Mart and more.  <h5><a href="http://ducknetweb.blogspot.com/2015/12/rite-aid-pharmacies-are-latest-to-begin.html">Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p><strong>Do pay cash when you can at the drug store for your own privacy benefits when you can, even though you risk being coded at an Outlier by the software, it’s less other data that can get linked to you.</strong> </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to FixOutliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p><strong>You can click on the image to read a short screenshot on what they do and if you as a patient are not in the 80% percentile, your pharmacist is required to hammer you to bring their numbers</strong> up so they can meet their goals and sometimes even keep their jobs, as the culling effect on pharmacist performance is out there as well as what doctors put up with today. <strong>If you are a diabetic and your pharmacy uses the EQUIPP program, the pharmacists are required to hit you up to tell you to ask your doctor about statins so more drugs can be sold</strong>.  Of course this is where the pharma business comes into play here as well to boost their sales.  <p>It’s to the point now where there are way too many consumers getting hit with the “co-pay” algorithms of the pharmacy benefit managers and the health insurers, so lawsuits have been filed.  As a matter of fact the pharmacy benefit management business is so profitable it’s the #1 revenue stream for United Healthcare, ahead of their insurance groups and we’ll see if Q3 is yet another barn burner for them with PBM revenue.  OptumRX also just secured a 5 year contract with CALpers to manage all of their drug programs worth about $5 billion.  <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p><strong>There seems to be some rotten algorithmic eggs out there slinking around in the pharmacy benefit management business</strong> and they all do it to some degree but some are much worse than others. <strong>With the recent CMS 5 Star ratings of Medicare D insurers, it’s starting to stink over there too.</strong>  CMS has been running models created by United Healthcare for years and now some of them are either failed in concept creation or are failing as time are failing.  Humana is now being hit with a loss of CMS money for not providing “quality” care.  We all know these surveys CMS uses are a joke and now the algorithms compiling all of this are at the point to where they are hurting the stock of Humana and Cigna, who again is sitting under the thumb of United Healthcare with the PBM OptumRX.  </p> <p>If I were Humana, and this is just me speaking I would consider suing CMS and Slavitt on this point, and Humana has already put out a press release contesting the 5 Star ratings.  What you are seeing here is a diminish of available insurance for consumers, using flawed and evil algorithms <a href="https://lh3.googleusercontent.com/-hnSHs9PwzoY/WAPN1Q-laQI/AAAAAAABM14/otqoznra0Lw/s1600-h/CAP3.png"><img align="right" alt="CAP" border="0" height="84" src="https://lh3.googleusercontent.com/-it-CR4E6LBE/WAPN1nZn-YI/AAAAAAABM18/BOXPg2y7vjQ/CAP_thumb1.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="CAP" width="240"></a>with United flexing their power where they can to gain an edge. It’s getting to be pretty visible if you look as that’s how they grew their business, math and algorithms.  Watch the 4 videos in the footer of this blog to understand how this works as there’s not a ton of difference between some financial models and tweaked health insurance models today. I saw this evolving way back in 2009, but it takes a while for more to clue in, I get that.</p> <p><strong>The incest of United Healthcare with HHS/CMS began years ago when Lois Quam, a former big VP at United Healthcare took a leave of absence from United and worked at the White House as the senior advisor to Hillary when “Hillarycare” was created.</strong>  You can also see a lot of this incest over at the John Postesta created CAP (Center for American Progress) with several former and current United Healthcare executives as “fellows”, some even earning the name of a distinguished fellow.  Currently former Senator Tom Daschle, a big lobbyist for Aetna is one of the CAP’s distingushed members, along with others such as Larry Summers as with their financial interests.  <a href="http://ducknetweb.blogspot.com/2016/01/zeke-emanuel-joins-venture-capital_14.html">Zeke Emanuel</a> and Jonathon Gruber can also be found at the CAP, writing US Healthcare policy as contributors. <h5><a href="http://ducknetweb.blogspot.com/2015/11/hhs-joins-optum-labs-as-research.html">HHS Joins Optum Labs as Research Partner–Back Peddles Support of FDA Sentinel Program That Does the Same Thing-More Impact from the Six Degrees of Bob Rubin Running Healthcare in the US</a></h5> <p>Here’s another good read written by a former CMS analyst and Tillman pretty much lines up every player in the ACA and their connections to United Healthcare along with their actions in turning healthcare in the US in to a “Cottage Industry”.  I would guess she should know after many years spent on the inside track involved in ACA policy.  It’s along read but worth it.  </p> <h5><a href="http://hardnoxandfriends.com/2016/01/10/hillarys-obamacare-fraud/">Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/ Optum, and the Center for American Progress</a></h5> <p>Good luck getting any real anti-trust action going here as our head of the Department of Justice is also a former United Healthcare anti-trust lawyer during the time she worked at Hogan Lovells (current lawfirm name).  If you <a href="https://lh3.googleusercontent.com/-XOP8Lxs0BLg/WAPN2c40UOI/AAAAAAABM2A/kaODx1jwYbU/s1600-h/Zeke8.png"><img align="right" alt="Zeke" border="0" height="64" src="https://lh3.googleusercontent.com/-hgWpC4FyWAE/WAPN2uX_9FI/AAAAAAABM2E/iLrV5UZX5lc/Zeke_thumb3.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Zeke" width="263"></a>look over there you will find a few former Untied Healthcare lawyers working there today, including the one who wrote this letter of recommendation to Grassley to approve her nomination.  In addition with the expansion of the large number of urgent care clinics that United/Optum has opened or purchased (MedExpress) they have even more outlets to push their OptumRX pharmacy benefits to patients to gain more revenue.  <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html">OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</a></h5> <p>So here we have it, two insurers, Cigna and United Healthcare both using the same OptumRX (owned by United Healthcare) <img align="right" src="http://lh3.googleusercontent.com/-dclAvjnezyI/Vi7i3HcWjII/AAAAAAABMkc/j5mxORCgLmA/image%25255B4%25255D.png?imgmax=800" style="float: right; display: inline">PBM management company, both front running consumers at the pharmacy counter.  I always tell people, pay attention to what’s going on with the  subsidiaries of big insurers and follow the data algorithms to really see what’s going on out there today as you see very little mention in major  news today as insurers are some of their biggest advertisers, so we know what that means…<a href="http://ducknetweb.blogspot.com/2015/04/news-rigging-has-arrived-astroturf-and.html">news rigging</a> (grin).  Don’t think because you fill your prescription at Walgreens that the OptumRX data is not there on the pharmacist’s computer, as it is, they are connected everywhere.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBMOptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p><strong>It doesn’t stop there either as “co-pays are in your veins” too with CVS buying Omni-Care and OptumRX with buying AxelaCare.</strong>  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/05/cvs-buys-omnicareselling-drugs-to.html">CVS Buys Omnicare–Selling Drugs to the Elderly Via Nursing Homes and Assisted Living Homes And Pays Over $2 Million Dollar Fine In California for False Advertising</a></h5> <p>Here’s another trick that is used to get more co-pay money from you from CVS.  <h5><a href="http://ducknetweb.blogspot.com/2014/10/cvs-to-charge-consumers-higher-co-pays.html">CVS To Charge Consumers Higher Co-Pays With Prescriptions Filled at Drug Stores That Still Sell Tobacco Products–Killer Algorithms Attacking Once Again To Make SureCVS Gets the Prescription Revenue And Your Data To Score And Sell</a></h5> <p>The data selling and predictive flawed modeling scores in healthcare and pharmacies needs an over haul indeed as today, it’s once again the consumer having to stay one step ahead of the “front running” of drug prices out there with the PBM algorithms that are there to test you and get more money from you every step of the way.  <p><strong>We just want fair drug prices and a stop to the<em> “tricky front running </em><a href="http://www.ducknet.net/attack-of-the-killer-algorithms/"><em>killer algorithms</em></a><em>”</em> that soak us for more money when we fill our prescriptions!</strong>   <p>Be sure and ask your pharmacist every time for the “cash” price and circumvent some of algo duping taking place out there today for profit.  BD <p> <hr> <script type="text/javascript" src="http://WVUE.images.worldnow.com/interface/js/WNVideo.js?rnd=703235370;hostDomain=www.fox8live.com;playerWidth=630;playerHeight=355;isShowIcon=true;clipId=12820629;flvUri=;partnerclipid=;adTag=News;advertisingZone=;enableAds=true;landingPage=;islandingPageoverride=;playerType=STANDARD_EMBEDDEDscript;controlsType=fixed"></script><a href="http://www.fox8live.com" title="FOX 8 WVUE New Orleans News, Weather, Sports, Social">FOX 8 WVUE New Orleans News, Weather, Sports, Social</a> A spreadsheet given to FOX 8 News by a pharmacist in the Midwest shows Cigna Health Insurance overcharged at least 70 customers for prescription medication in one month, at just one community pharmacy. The spreadsheet details how the insurance company paid the pharmacist $25 for an acne cream. But Cigna instructed the pharmacist to collect a $187 copay, overcharging the customer $167. That money went right back to Cigna. <p>"One of the claims that we brought in the case is a RICO case, a racketeering case," says plaintiffs' attorney Craig Raabe. "And part of the racketeering case is a scheme to defraud - essentially an entity is engaging in fraud use through interstate commerce. And that creates the racketeering. So, it's a term of art in what we do, but in common sense terms it's fraud - saying one thing and doing another." A Massachusetts woman filed the class action lawsuit against Cigna at a federal court in Connecticut, where Cigna's corporate headquarters is based.</p> <p><a href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash" title="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash</a></p>

Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers. ...

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Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries

<p>If you don’t know what a Quant is, take time out and watch video #2 in the footer of this blog as they are not just limited to working at financial firms.  As a matter of fact, hedge funds and banks can’t hire enough of the and the same holds true for insurers and other healthcare entities.  These are the math wizards today that are working without a net of any “proof of concept” any more and are just tossing a lot of models out there to see if they stick.  I know that’s a crummy way of putting it, but that’s the reality of folks being soaked on models and numbers<a href="https://lh3.googleusercontent.com/-QO1huLc4Ves/V92AEN8UY9I/AAAAAAABM0E/wF13WZgVGJU/s1600-h/image%25255B15%25255D.png"><img align="right" alt="image" border="0" height="78" src="https://lh3.googleusercontent.com/-CtZcwaQXId4/V92AE7cCDcI/AAAAAAABM0I/5rN3NG1tJRI/image_thumb%25255B9%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="244"></a> they don’t question, it’s the Dupes of Hazard society that exists everywhere today.  What the Quant do well, is to use math to create profits, no matter if it hurts individuals or not.  Look at what was recently done at Wells Fargo with the low level employees, as they didn’t just decide to sell fake accounts on their own, there was a pay for performance model created by quants with a number of carrots and probably some sticks attached.</p> <p>If you have not heard of the Optum 360 subsidiary, the link below will explain how it works and how the subsidiary solicits hospitals and other healthcare entities (now Quest Labs) to hand over their billing, also know as revenue cycling with the big hopes of saving money and collecting more money.  Employees are usually let go by the healthcare entity and rehired as an Optum 360 employee with maybe less pay and worse benefits.  I read some of the reviews from Dignity Hospital reviews on GlassDoor and they said the benefits were a lot worse once they came under the Optum umbrella.  You could almost say it’s an internal US H1B process as the pay and benefit results seem to follow the same pattern.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/04/mayo-clinic-is-latest-to-outsource.html">Mayo Clinic is the Latest to Outsource Revenue Cycling to Optum 360, A United Healthcare/Dignity Health Company Pursuing Hospital Contracts All Over the US For Profit…</a></h5> <p>The real deal here of course is the access to all the data as the data miners and sellers of the healthcare industry will take the data, score you and put the data into other “new” data bases and turn around and sell it.  This process is called repackaging and when this occurs, most of the time as consumers we have no idea where it goes or who originated the data.  As long as prescription data is not taken from a HIPAA covered entity such as a medical record, it’s out there for sale to who ever has the money.  Quest is also promoting their own “outsourcing” program with hospitals and <a href="www.prnewswire.com/news-releases/quest-diagnostics-completes-acquisition-of-clinical-laboratory-partners-outreach-laboratory-service-business-in-connecticut-300227605.html">just bought another hospital lab service,</a> so that makes about 5 or more they have bought.  20-30% of the services performed for hospitals with this service end up going to their own Quest diagnostic centers to be worked.  </p> <p>Subsidiaries of companies are something I have told all for years to pay attention to as that’s where all the data work is done and<a href="https://lh3.googleusercontent.com/-sUPaYPmhyqY/V92AFd84B4I/AAAAAAABM0M/LqEegYGImOk/s1600-h/image%25255B4%25255D.png"><img align="right" alt="image" border="0" height="138" src="https://lh3.googleusercontent.com/-DCiT1MZO3zc/V92AF8wyKTI/AAAAAAABM0Q/WM0FsT80Jtc/image_thumb%25255B2%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="288"></a> computer code is written to create big profits with running proprietary code that nobody ever gets to see or audit for accuracy.  </p> <p>ScriptCheck, offered by ExamOne, a subsidiary of Quest Diagnostics is a big data mining firm, and so how many were not aware that Quest has been in the data mining and selling business for years?  Anyone buying a life insurance policy could very well be investigated and a full data pull created to get information for underwriting.  Sure we know some of this is necessary, but when do they cross the line?  Any more it’s all the time as the data gets repackaged and resold with data mining.  They take the list of meds and try to “guess” what medical conditions you have or “might” get.  That’s the scary part is the “might” or what is abused today and openly called predictive analytics.  In this <a href="http://articles.latimes.com/2013/oct/21/business/la-fi-lazarus-20131022">article written in 2013, David Lazarius</a> does a pretty job with explaining how this works.  <p><strong>There is an update though as ExamOne bought a bunch of Ingenix (now called Optum Insights) algorithms in 2014</strong>.  We maybe all know that the former Ingenix subsidiary of United Healthcare is where current acting CMS administrator Andy Slavitt called home for a number of years and was taken to court over cheating on out of nextwork payment for MDs by using formulas beyond comprehension of most to inflate United Healthcare profits. <strong> I call it “Code Hosing”</strong> when I see this occur as you and I as a consumer have no access to either the math or the models used to create these profit centers and it ends up being a bunch of <a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">quantitated madness due to the fact that people are afraid to contest any form of math,</a> good math or bad math. <p><a href="https://www.linkedin.com/pulse/20141027182707-39299902-examone-acquires-assets-from-optuminsight?forceNoSplash=true">Heres a few clips that tell you all about Quest Diagnostics ExamOne service</a> and their purchase of the Ingenix MedPoint (OptumInsights) Algorithms in 2014 and what ScriptCheck is all about.    <p><em>“LENEXA, KS, October 27, 2014 / -- ExamOne, a Quest Diagnostics company and leader in helping insurers meet their underwriting needs, is pleased to announce the acquisition of certain proprietary assets from OptumInsight that support the ability to provide rapid responses to data inquiries for use in life and health risk assessments. The acquired assets will streamline and improve the ScriptCheck® service offered through ExamOne.”</em> <p><em>Along with ExamOne’s expansive suite of insurance services (also known as Policy Express) the acquired technology is designed to accelerate the underwriting process, improve risk assessment, assess the accuracy of health statements and discover undisclosed doctors<img align="right" border="0" src="http://lh5.ggpht.com/_v3zjJigoAPE/SkL9GOgy_rI/AAAAAAAATec/4yxb2jf7CV8/image_thumb%5B5%5D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px"> or medical conditions for underwriters.</em> <p><em><strong>About ExamOne</strong><br>ExamOne has provided a portfolio of services to the insurance industry since 1972. It has grown significantly through continuous innovation that meets the evolving needs of life, health and disability insurance providers and their customers. Laboratory testing was part of the company’s original services, which over time have expanded to include paramedical examinations, fraud detection, electronic data collection, and gathering attending physician statements and motor vehicle records. ExamOne also has expanded into helping individuals learn about their own health through its Inside Look™ product.</em></p> <p>Part of the real scary part about this agreement is that now Optum also will be able to get any biometric screenings provided by Quest as well.  We have all seen the nighmare Orwelian companies like Red Brick (which was started by a one time United Healthcare young exec) that are into<a href="https://lh3.googleusercontent.com/-DRG5tPihlZE/V92AGSOr7MI/AAAAAAABM0U/O5NN6zkMnyk/s1600-h/EQUIPP%25255B5%25255D.png"><img align="right" alt="EQUIPP" border="0" height="457" src="https://lh3.googleusercontent.com/-rKZvRY4yzrk/V92AG2s461I/AAAAAAABM0Y/Rc7GljKudEM/EQUIPP_thumb%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="EQUIPP" width="449"></a> monitoring every move we make and this looks like an open loop hole here for United Heatlhcare/Optum to get that data, what else can you say?  There’s nobody in their right mind that wants their insurance company to have all types of data and information that the insurer could easily miscontrue and take out of context to avoid paying a claim!  That’s what this does.  Actually it’s not just Quest and United Healthcare/Optum deal alone, we have a huge problem of “Excess Scoring” in the US taking place with consumer using flawed data, queries and proprietary code to where we do not have the ability to even correct it.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html">Excess Scoring of US Consumers, US Citizens-Scored into Oblivion By Proprietary Algorithms and Formulas, Never Duplicated or Tested for Accuracy-Profits of Big Business And A White House Executive Command To Continue the Abuse..</a></h5> <p>If you get a chance to talk candidly to pharmacists today, they’ll tell you all about what’s going on and how you are “scored” with every prescription you fill too.  There’s this EQUIPP program out there that tells them what to do and how to dig in and find outliers, some of which are diabetics who are not on statins.  The pharmacists who are forced to work this EQUIPP program model have to find their “outliers” or they could end up like the employees at Wells Fargo and be be out of a job if they don’t play the game.  In the drug industry, they couldn’t get doctors to push statins and other monitoring flawed data programs, so now the boom is lowered on your retail pharmacists who need their jobs.  Click on the image at the right and see what I’m talking about.  <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>So my guess here is that with United Healthcare/Optum having this new additional data of labs to query into the prescriptions, your lab tech could very well be the next person out there suggesting not only monitoring but also in a round about way, pushing more drugs.  <p><strong>This really even gets more interesting with the Quants of Optum and their models for profit as United Healthcare has a contract with LabCorp as their exclusive Lab and has had that contract since 2007.</strong>  Optum and United Healthcare already get all that lab<a href="https://lh3.googleusercontent.com/-k-dnOpmw8Ow/V92AHa6pxII/AAAAAAABM0c/SxBgk_dHybQ/s1600-h/image%25255B19%25255D.png"><img align="right" alt="image" border="0" height="101" src="https://lh3.googleusercontent.com/-W_L3qRa38CQ/V92AH4GFwtI/AAAAAAABM0g/qfsi9ppy29s/image_thumb%25255B11%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="187"></a> information from LabCorp and the contract continues until 2018, so that’s what makes this Quest deal interesting and data rich with data selling.  If patients all over the country are already being directed to LabCorp facilities, how would Optum get a chunk of this money?  I suppose the answer is what just happened with the Optum 360 subsidiary now getting do most all of the billing for Quest Diagnositcs, right?  <p><strong>Talk about quants working over time working both models of each lab to increase revenue, right?</strong>  Again watch video #2 in the footer and learn what a quant does as we have that same mentality running CMS with Andy Slavitt being both a former McKinsey consultant and a Goldman banker running everything.  All he is concerned about is numbers as he’s just an Algo Man who cares little about anything else.  Follow him on Twitter and it’s not hard to see at all. <h5><a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">The Rise of the Quants, Again! This Time In US Healthcare- Taming the MACRA Beast of Quantitated Madness For A Lot of Things That Are Probably Just Not True</a></h5> <p>So what happens when you get a lab test done?  Depending on the result of course, you might get a prescription for a drug, we all know that by now (grin), so look at how this data mining is working today.  With Optum having all the lab information will this have a tendency to push more drugs, and the drugs that are covered by pharmacy benefit managers that make the most profit for them?  It is not far fetched in my book <a href="https://lh3.googleusercontent.com/-XgfibL-ArlQ/V92AIYYGhaI/AAAAAAABM0k/HXiYtXMIqGc/s1600-h/image%25255B9%25255D.png"><img align="right" alt="image" border="0" height="194" src="https://lh3.googleusercontent.com/-suvBkbofYL0/V92AI4FEAxI/AAAAAAABM0o/4R765Soth94/image_thumb%25255B5%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="265"></a>at all as I used to work with data, wrote software and it’s how the mentality works.  If you haven’t noticed by the way, the OptumRX is the largest revenue stream that United Healthcare has now, larger than each of their insurance groups when compared.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>So this is adding yet another element of behaviorial scoring and data mining for profit if you will and we’re not getting any breaks on cost.  As a matter of fact, this is a good link to look at that explains the coupons and discount cards at the pharmacy, as they tell you how it works. </p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <p>Again, look at the subsidiaries of these big corporations and what are doing with data for your answers as it’s all there as the<strong> quants in healthcare keep modeling away to attain the best models for profit,</strong> not necessarily for better care, Moneyball as Optum calls it, which really only works well for baseball where everyone knows the rules, but with healthcare the rules change every day.  BD <p> <hr> UnitedHealth Group Inc.’s Optum health-services arm has struck a deal to oversee billing processes for lab giant Quest Diagnostics Inc., substantially expanding its growing business of handling such transactions for health-care companies. Under the 10-year pact, Optum will take over a number of key revenue-related services for Quest, including billing health insurers and consumers, and collecting and processing payments from both. About 2.400 employees who did such work for Quest will become Optum employees, but they will generally remain physically in their current locations.</p> <p><a href="http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800" title="http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800">http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800</a></p>

Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries

If you don’t know what a Quant is, take time out and watch video #2 in the footer of this blog as they are not just limited to working at fi...

Read more »