Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…

How many companies used the Ingenix Data Base one has to question.  While current Acting Director of Medicare, Andy Slavitt was the CEO of Ingenix it appears he was quite busy.  This case, as you can read below per a recent decsion is now allowing doctors to cotninue with their case for the use of the flawed Ingenix Data Base.  Upon taking the position to run Medicare, HHS Secretary Burwell was able to get an unprecedented pardons in place for Mr. Slavitt to avoid all these lawsuits.  Does that set well with you?  It happened.

Connecticut General Life is the primary focus here with Cigna being the insurer providing the reimbursement.  This change probably hits Cigna at maybe not a good time when they are trying to merge with Anthem one could say, although there a lot more to the complex merge as well.  Cigna paid the claims, and thus the ruling is to now allow the case to proceed.  Last year, this Ingenix lawsuit was just settled as well with surgical centers also being short payed by Ingenix.  Ingenix had a name change to Optum Insights a couple years ago and I think all the lawsuits might have had something to do with that. 

Another United Healthcare (Ingenix) Lawsuit Settling Over 9 Million-Short Paying Ambulatory Surgery Centers-Current CMS Director and One Time Goldman Sachs Banker, Andy Slavitt was CEO of Ingenix for Years…

In addition, this case with Ingenix just settled last year as well.

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

In addition, this group of lawyers in New York appears to be investigating the potential of another lawsuit with United, relating back again to payment of claims.

Law Firm Investigating UnitedHealthCare Claim Payments in New York Stating Under-Reimbursement By Manipulating Algorithmic Benefit Calculations…

A couple years ago, and it received very little publicity, the Supreme Court put out a ruling allowing doctors, to be able to group to worth together on such cases of unfair business practices as well. 

US Supreme Court Rules Physicians Can Work As A Group To Fight Unfair Business Practices of Health Insurers–Victory Over United Healthcare (Oxford Subsidiary)–Context Once Again With Contracts

Almost all the major insurers were hit with the under payment legal cases as they were all licensing the use of the Ingenix Data Base that allowed calculations to short pay doctors and patients for out of network claims.  Aetna ended up waiting long enough and in the end weaseled out of their payments with some quick work by the company that somehow showed a lack of interest had developed.

Aetna Payment of $120 Million To Settle 15 Year Ingenix/United HealthCare Out of Network Erroneous Payment Algorithms Cuts Income for 4th Quarter

The big case of course that everyone may remember was the large class action suit that the AMA filed against Ingenix and won against United Healthcare Ingenix, and their CEO at the time, current CMS Acting Director Andy Slavitt.  The post was Chapter 19 of my old Killer Algorithms series to where I wrote about algorithms and formulas attacking consumers with either denying access or taking more money. 

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 the Killer Algorithms Chapter 19

Ingenix itself was very busy as a subsidiary of United Healthcare securing Health IT contracts and buying up other companies as well.  As a matter of fact, all the bogus “medication prediction scoring” that we are all subject to when filling a prescription was all started with Ingenix algorithms being licensed to Express Scripts in 2010.  I call it bogus as I am referring to the prediction portion of this and not the actual monitoring of hard data.  If you look at the 300 metrics used by Express Scripts and some of the other pharmacy benefit managers with their proprietary calculations, they have nothing to do with taking your prescriptions and predict with flawed calculations on whether or not you will be compliant.  As an example, if you have kids, that’s one bad ding for your score. 

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

So back on track with Cigna here, they can’t seem to get out of being associated with United Healthcare either with some of their business.  United Healthcare is racking in big pharmacy benefit money as their acquistion of Catamaran turned United into the Cigna pharmacy benefit manager.  If I were Cigna running an insurance business I’m not sure I would be too happy with that with a competitor now running the pharmacy benefit end of the business?  It’s been stated that the Anthem/Cigna merge may not complete until 2017. 

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

So this case is rolling along, and the judge did decide that individual doctors and medical associations can’t file additional claims, and nor can it turn into a class action suit, but the current plaintiffs have the OK to collect from Cigna on the use, once of the flawed and corrupted Ingenix data calculations for paying doctors.  I sometimes wonder how much money Ingenix/United Healthcare really racked in from all of this as it went on for 15 years, had to be a bunch with all the licensing to so many other insurers as well. 

Ingenix (Optum Insights) folks have been hanging around Washington DC for quite a while and you can kind of see this going back to HHS just gushing over their “Reach for The Top” model, link below from 2010.  It contains pretty much all the elements CMS is pushing and marketing today, Population Health, paying doctors less and so forth, so the influence and math models and algorithmic plan association here leaves no doubt and perhaps all these models is what maybe convinced Secretary Burwell that in addition to all the Ingenix lawsuits that Slavitt was the correct person to run Medicare?  Go figure I guess.  We all knew before Burwell we had the affliction of the Sebelius Syndrome with her out of reality perceptions and chasing those Algo Faires too for perceived solutions.    BD 

"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

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May 2 — Out-of-network health-care providers have ERISA standing to continue with their lawsuit accusing Connecticut General Life Insurance Co. of using a manipulated database to determine their services fees, the U.S. Court of Appeals for the Third Circuit ruled. In the May 2 unpublished opinion, Judge Thomas I. Vanaskie reversed in part the district court decision that had seemingly put an end to a decadelong litigation. Vanaskie remanded the case to the district court, holding that the providers had sufficiently pleaded the existence of a valid assignment to support derivative standing under the Employee Retirement Income Security Act.

The proposed class action was originally brought by medical providers, individual subscribers and 14 medical associations, alleging that out-of-network services were underpaid because of flawed “usual, customary and reasonable” (UCR) rate data provided by Ingenix Inc.

The providers' allegation that they received from CIGNA insureds an assignment of benefits or a claim assignment through which they were paid directly by CIGNA was sufficient to plead the existence of a valid assignment to support derivative standing, the court said.

http://www.bna.com/cigna-cant-avoid-n57982070578/

Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve

If you have watched the news of late, drug prices that we pay are a big item as the price of drugs keeps going up.  The pharmacy benefit management company is the middle man in between the pharmacy and you.  Their computers connect to the PBM and they are given the price to charge you according to your  agreement and insurance under which your prescriptions fall.

Worth a mention here is that OptumRX last quarter became the biggest revenue producer of their 4 revenue categories.  That’s right they are making more here than any of their insurance groups when compared, more at the link below.  OptumRX gets a double whammy in revenue as their OptumRX, through the acquistion of Cigna is also the pharmacy benefit manager for those insured by Cigna.  Cigna is currently sanctioned by CMS though and and their former benefit manager, Catamaran, which was acquired and integrated into OptumRX was denying patients too many drugs and care.

United Healthcare Hits the Bottom of the Barrel Linking Doctor Information to Healthgrades Flawed Data

Of course in this video, which pharmacy benefit management company is heavily connected to claw backs?  United Healthcare, aka OptumRX. You may have wondered why we have the Walgreens and OptumRX agreement right?  There’s claw back money potential here as they state that patients can pay the same at Walgreens as they would getting a 90 day supply via the mail.  Well, when you watch the video, the computers talk to each other and the patient may receive a higher cost than what the Walgreens “no insurance-cash” rate would be.  So what do they do, split the difference with a profit?  More at the link below on how this happens.  Anthem is suing Express Scripts as well on the pharmacy kick backs that the pharmacy benefit management company Express Scripts receives on the sale of drugs.  That’s another avenue in which pharmacy benefit management companies make money, they get a kick back from the drug company on the dollar amount of the drugs that were sold. 

Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts

Some day if you need infusion drugs, there’s a good possibility a subsidiary of OptumRX, the subsidiary of United Healthcare might pay you a visit for that too as the company they bought operates in 38 states.

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…

When you really want to throw off the entire pharmacy patient “scoring” system, just pay cash for your prescriptions and you’ll be scored by default as an outlier who doesn’t take their meds.  Before you walk in to most pharmacies today, the pharmacists already have you sized up with 300 metrics that have zero to do with taking your prescriptions on predicting whether or not you will.  I think it’s a big farce, costs a lot of money and they sell all of this data to insurers and other people who want to calculate any type of risk assessment on you.  The problem is, the numbers are flawed. 

Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Nonmedication Adherence Compliant With 5 Star Systems Full of Flawed Data…

Do always ask for the “cash” no insurance price is the moral of this story to avoid pharmacy benefit managers getting a claw back of your money and charging more when they find you could be asleep at the wheel if you will.  In the video they ask what kind of company is that which is supposed to negotiated cheaper prices for you and ends up charging you more?  That’s a good question and of course some of that probably goes to pay for all the software and algorithms that score you on predictions and risk, right?

Sometimes customers are paying more than the drug is worth as well.  Claw Backs don’t occur on every prescription but ask to avoid one happening with you is the best advice.  I had a person tell me they have a son who needs some expensive drugs due to some serious conditions he has and due to the pricing, he has to go to three pharmacies to get all the prescriptions for the best price.  That’s wild when that occurs but that shows how different the contracts are and how the pharmacy benefit management contracts work.  BD 

KFDA - NewsChannel 10 / Amarillo News, Weather, Sports

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One source for our investigation, a New Orleans-area pharmacist, asked us to hide his identity.  Contracts with pharmacy benefit managers, or PBM's, prevent him from talking publicly.

But documents that multiple pharmacists provided to FOX 8 News show, in some cases, companies are charging copays that exceed the customers' costs for their drug.  

Pharmacists call it a clawback - the company is essentially clawing back money from you and, our source tells us, you probably don't even realize it's happening.

“They have no idea,” the pharmacist says.

“Whatever the insurance company/PBM tells us to charge as a copay, we have to charge the patient for that,” our source says.  “We cannot discount it, we cannot forgive it. Our computer calls their computer. They tell us charge the patient this much money.”

But many pharmacists, who asked that we not reveal their identities, gave us dozens of examples. They include a $22 clawback on a nasal steroid, fluticasone; $7.85 for a diabetes treatment, invokamet; $12.39 for diazepam, a drug that treats anxiety, muscle spasms and seizures.

http://www.newschannel10.com/story/31891070/zurik-copay-or-you-pay-prescription-drug-clawbacks-draw-fire

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

I’ve been watching this for years with the way healthcare is changing in the US today and we certainly need and do use constructive and good measurements in what the industry does, but just like in the financial world, we’re starting to cross some borders here into madness where mathematical models with “no” proof of concept even are producing numbers that don’t compute and host environments that are hostile to the future of providing good care.  In other words, it’s time to take to take a step back and look at where we are and it’s not pretty nor productive in a lot of business areas today.

It was back in 2009 I started noticing the correlations of what was happening in the financial world and compared it to what is taking place and healthcare and when you do a bit of research and reading on this topic, it’s not hard to figure out that some of the healthcare models are not much more than some of the financial models that have been tweaked a bit to try and perform the same linear methodologies that are either flawed from the start, or that contain proprietary computer code that developers have been selling with the tag line “trust me”. “Trust me” is becoming a huge problem as proprietary software and algorithms are all locked up in what is called a “compiler”, in other words nobody without proper credentials can see what the magic sauce is. 

There are good reasons to have some “magic sauce” around though and folks patent a lot of it.  Back in the early days of the mid 90s, when all were working to create tools that actually helped us with business this was not really an issue, but the world has evolved today and that’s not always the case.  We can look at Volkswagen as an example, which we all should know by now; they cheated with their computer code and built a “virtual world of cars that did not pollute”.

With software you can do something about anything, and the methodologies can be true and they can be false as we learned.   I borrowed that line from the video documentary about the Quants of Wall Street, the Alchemists and if you have not seen it, scroll down to the bottom of this page and watch it, as we have tons of Quants in Healthcare today, just like we do in finance. 

Data Scientists/Quants in the Health Insurance Business–Modeling Beyond the Speed and Capabilities of Humans To Keep Up With The Affordable Care Act–Turning Into A World of Killer Algorithms That We All Hate..

I read every day with the frustrations of the average consumer trying to make sense out of what’s going on and they can’t.  This is a world controlled and ruled by individuals who are both responsible and irresponsible in what they design and create out there and both exist.  All one has to do is look at Wall Street and know there’s a lot of folks up there who cheat with computer code, an issue that even those who are elected to make laws in this country can’t understand, and that’s scary as that’s their job.  Former Head of the Department of Justice, Eric Holder, determined he didn’t want to explore this avenue of crime either and turned his head away from having to deal with crimes that are committed with cheating with computer code and math models.  We saw that plain and clear in the PBS documentary called “The Untouchables”.

I used to write software and I look at what some of the journalists put out there today and truly I ask myself “where in the hell did they get that interpretation” with some of the news articles?  Again just like the average consumers, they don’t understand or make an effort and we get “junk” news and interpretations.  There are some good exceptions out there though, with real journalists, and not jounobots that do dig in and create some good articles, so this not an attack on the entire industry, just the ones who are blinded with Perception-Deception and produce a lot of just with quantitated madness statistics on things that are not true.  We all know at this point that a lot of the news we read today is “rigged” and the complaints are numerous. 

Media newspapers are running out of money to put out the news as Facebook and a few others have taken a lot of their ad revenue which is used to support them and wrapped it into their news feeds which also use algorithms to tell you “what you should read”.  God help us with the dupes that are totally sucked in there as well.  I call it the Dupes of Hazard society today.  Take a look and see how easy it is to produce fake news today with a bot that does all the writing.  One bot is so good that the creator used it to create 10,000 books and put them on sale at Amazon.  These jounobots are not just restricted to writing content either; you’ll find them writing content to verbally justify a lot of quantitated madness we deal with today. 

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…

So now we move to the next level of quantitated madness out there with the new CMS MACRA rules for grading doctors.  We all know that the Meaningful Use model has bit the dust and logically, all models are not created to run forever, as some might think.  If you talk to a good Quant though, they will pretty much tell you that you can’t take another model, load it on top of a model that’s already broken and expect a good “fix”, and that’s what I see happening here.  There’s almost a 1000 pages of quantitated madness that is going to reward doctors for better care?  We do need some reporting and that’s the point of this post, the point is that with putting a new model on top of one that is already broken, well guess what, this one will be broken too. 

Broken models are not fixed by created yet another model on top and lead us into very complex areas of math to where nobody will understand what’s going on.  With that in mind, health insurers have done this for years and I’m not the first to state that they make money based on complexities and keeping consumers “off balanced”.  Insurers have a captive audience and they know it and have been modeling like this for years!

Others know this as well so I’m no genius with this conclusion at all.  As a matter of fact way back in 2009 when Sebelius was nominated to run HHS, before she ever stepped foot in that office, I said exactly this would occur, that insurers would reduce her to mincemeat as she’s out of the same mold at Eric Holder was with not wanting to deal with reality and how those smarter than her would use their quantitated skills to model all over her and get what they want, the insurers.

Kathleen Sebelius, Kansas Governor for HHS – Please not! Put the “Smart” People in these key positions

So not much has really changed in essence from that day and we are still continuing on the same path.  I call it STAT RAT FEVER as my own coin when I talk about the government’s activity in healthcare as that’s all they do.  Currently we have two folks running HHS and CMS that were former McKinsey consultants.  If you have not read some of the books out about the brain washing institute, do it and you’ll understand what goes on. 

I call it the “Scientology effect” of the business world as you find their consultants everywhere and some have even gone to jail.  Recently we had Mckinsey written all over Valeant, who again before he was the CEO of that company, was a long time McKinsey consultant.  Almost anymore when I see any study from McKinsey using the “T” word, “trillion” that could be saved, you have to laugh as they use quantitated madness reports to get you upset and motivated to believe whatever kind of numbers they want to sell that day.  Of course if you go back in time and look up some of their old studies and compare them to what has really occurred, you do find a lot of fictional marketing in some of what they have published.

We do have one doctor at the ONC who is no longer the chair person, DeSalvo who for about a year bit on the perception-deception tall tale that medical record developers were deviously writing code not to interoperate.  That was a marketing ploy of a big EMR company that was planted out there as “marketing” to make people think that medical record vendors were “on purpose” writing code that would “block information”.  Of course anyone whose’ been in the business long enough knows that’s a farce as it takes time and money to write code and no vendor is going to do that, and maybe they just didn’t have the time, money and resources to write enough code yet to match her perception of what interoperable code should be (grin).  I thought it was great when Dr. Halamka addressed it for what it really is, and he’s a doctor and a computer scientist at Harvard Medical and if anyone knows what the correct perception is, he does.

“Information Blocking” Finally Revealed for the Hoax and Make Believe Story That It Is With Medical Records Sharing and Interoperating…

So hold on to your hats with MACRA as both Burwell and Slavitt are both former McKinsey consultants, where some basic training was attained, if you will.  Neither have any backgrounds in the clinical side of healthcare so at some point, one has to ask, why don’t we have some folks with clinical backgrounds at the top of the helm in government healthcare?  I think it’s a good question.  We can all go back and see the long extensive background of Andy Slavitt with his former position at CEO of Ingenix, which was renamed to Optum Insights and how when thing got really hot over there with all the lawsuits, United Healthcare folks just moved him over to run QSSI when United purchased that company to get in on some of the Healthcare.Gov action with more algorithms and software.

In addition the “do not disturb”  sanctions given to Slavitt at CMS were unheard of.  All those lawsuits would distract him from doing his job?  Well why don’t we look at how and why all those lawsuits came to be?  He’s a Quant and also spent some time at Goldman Sachs, and the banks really heavily on their Quants to model their financial models.  If you happened to see “The Big Short”, they offer an explanation there as to “what a quant does” in a humorous way.  You hear “listen to my quant”, and that indeed was a good portion of the movie that tells you right there what the quants are hired to do to ensure profits.  It was funny in the way that the quant was presented as an Asian individual who didn’t speak English, but could write good code and then there was the insert of him blowing that perception into the dirt as he explained “what he really does”. 

There’s a lot of models out there that don’t work.  One of the most well known examples is the Bloomberg Big Gulp.  The developer of that process actually ended up leaving Bloomberg and went to work at the CDC and created yet another model that didn’t work called Obesity for the Workplace.  Again these are theories and some kind of numbers that may or may not work.  It’s hard sometimes not to get caught up in the perceptions at times too as we are presented with a ton of mathematics that say it will work.  As we all know by now, the Bloomberg Big Gulp mathematics failed as “people don’t work that way”.  I see it time after time when quants and developers think they have “the answer” with a vision in their heads on how people will work with their code and models and it flops.  There’s no easy answer to a lot of it as well and you need at least some proof of concept developed, but we don’t even get that anymore.  I speak of this as I got fooled too in this game and saw it a long time ago.  You think you have the answer only to find out you don’t. 

When the financial stakes get high though, you do get marketing folks called in to write all kinds of quantitated justification stories as to why it has to be the cat’s meow and the peanut galleries on the web, toss out all their potential skeptic feelings and simply just buy in to the madness.  I wrote about this a while back and called it “Operation Perception-Deception” in the US before everyone else started jumping on the same band wagon.  You implement enough failed models and people eventually stop drinking the Kool-aid.  In addition, some of the skewed quantitated madness has people just flat out doing strange things with attacking symbols like flags and so forth, as again they are wrapped up in a world of technology that they can’t see or understand, with a very small number of Quants and developers creating algorithms that are denying access and eventually taking away a lot of our freedoms in the US. 

Operation “Perception-Deception” Into Full Swing in the US, With Killer Algorithms, Algo Fairies, Algo Duping, The Grays, and Of Course, Flags As Consumers Confuse Virtual World Values With the Real World…

If I were a doctor today being subjected to this new grading system, which is basically a re-write of a lot of what United Healthcare has been developing with a lot of their models, I would be a skeptic indeed.  When you look at the fact that CMS sanctioned Cigna health insurance for not providing quality care, and then took away their penalty (nullified the rules of the game) and then come back with this to grade doctors and think it’s going to create better value for care?  We have some folks out there not looking at big picture.  Admittedly the health insurance models for grading has failed so what makes you think this MACRA model is going to be an accurate representation?  Think about that. 

I’ve learned some of what I know from mathematicians that work for universities that have written and put out some extensive work in this area.  Charlie Siefe at NYU in Mathematics has been very outspoken and if you watch video #1 in the footer, you can learn a lot from just one video.  He also wrote the book called “Proofiness, the Dark Arts of Mathematical Deception”.   I’ve also had some chats with Ed Frenkel, mathematician at Berkeley and we all seem to be on the same page.  A quant is both a mathematician and one who writes code.  Watch video #2 in the footer to understand how they function in the financial world and you can easily see how their work slides right over into healthcare, especially when there are profits to be made.  This is the real deal out there today. 

How do we know that MACRA is not going to turn out to be another Bloomberg Big Gulp type of model?  There’s no proof of concept, no pilot, it’s just a matter of tossing a bunch of quantitated madness out there that they “think” will be able to create value in healthcare.  At this point with all the complexities of this 962 page model of mathematical complexities I think it’s a good idea to read the post from Dr. Halamka, CIO of Harvard Medical, who for years sat on the committee to help guide the ONC and HHS on their models…basically it’s a monster that provokes one to think about leaving the practice of medicine.  He’s smarter than anyone in government who’s responsible for creating this model of madness that has no proof of concept what so ever.

Again as I mentioned early, you can’t put a new model on top of a broken model that’s already failing and hope to have a good fix, it just won’t work and you need a model that doctors can work with and not a ton of quantitated madness for things that just maybe not be true.  When it comes to models, I think we all know or should know by now that United Healthcare has been the mentor in place at HHS for a long time and there’s tons of documentation all over the web that substantiates this.  I still think about the New York Times article from 2009 when Senator Rockefeller asked both Slavitt and the CEO, Hemsley of United “how do you folks sleep at night”, link to the post below.  

Is This a Case for a New Law – Illegal Algorithms? How Do You Sleep at Night Rockefeller asked the CEO of United Health Care

Here’s another comment from a doctor on the entire MACRA process…and I’ll close with this.  BD 

“When Blumenthal was at ONC , he understood doctors needed to see patients, and the EHR was one of many tools to help doctors care for patients. Farzad got us off track with insane busy work in stage 2, on now we are completely off the rails.”