President Obama and his legion, Pelosi, Reid, Stupak, et al, have said basically that once the American people get to know what’s in the healthcare legislation, they’ll actually like it. We all know how very important it is to the President and Speaker Pelosi that the American people be happy.
One must assume, based on the President’s assurance, that once we get to know this health care reform legislation up-close and personally, we’ll be so happy that we’ll all gather on a hilltop and hold hands to sing a groovy song and will vote unanimously to usher in a new age of Aquarius.
Okay. Let’s see if that works.
Here are a couple of things I learned about this legislation since its passage that I had not known previously.
• When you buy your federally mandated, IRS enforced – either by penalty of a fine or imprisonment – health care insurance you may be buying from an insurance company that will donate a portion of what you spend for your insurance to a special fund to help pay for abortions. It is now mandatory that certain insurance carriers provide a portion of what you pay them for health care coverage to a special abortion fund – Stupak’s hastily scribbled hall pass aside, this is now law.
o There is no special fund for Breast Cancer
o There is no special fund for Heart Disease
o There is no special fund for Diabetes or MS
o There is ONLY a special fund to pay for abortions
• When you sell a home in Mr. Obama’s new and improved America a 4% tax will be levied on your proceeds from the sale which will go to cover Health Care costs.
• Tanning? Apparently Dems want us all to be pasty for some reason…if you frequent tanning salons, you will pay a 10% excise tax.
• Mobility be damned! If you purchase a wheelchair, you will pay a 2.3% excise tax. I’m sure those confined to wheelchairs will consider this to be a great step forward in care.
• Pharmaceutical companies will be allowed to pass a $3 billion annual fee on to you, the consumer, in the form of more expensive drugs and medication.
• About those fines – Citizens who don’t purchase insurance would be subject to a fine of $325 in 2015 and $695 in 2016. Individuals may be subject to a charge equal to as much as 2.5 percent of their income in 2016.
• The Medicare payroll tax will now be applied to investment income, beginning in 2013.
o A new 3.8 percent tax will be levied on interest, dividends, capital gains and other investment income for individuals making more than $200,000 a year and couples making more than $250,000.
• The Medicare payroll tax will increase by 0.9 percentage point to 2.35 percent on wages above $200,000 for individuals and $250,000 for married couples filing jointly.
• A 40% tax on health benefits happens in 2018 and applies to premiums exceeding $10,200 a year for individuals and $27,500 for families. In other words, that phrase – “If you like your current insurance, it won’t change” was a big fat lie. If you have great insurance, you’ll now be taxed for the privilege. A 40% tax is a change.
• Taxes and more taxes –
o According to the Joint Committee on Taxation, a nonpartisan agency, this legislation will generate $409.2 billion in additional taxes by 2019. The Congressional Budget Office also says that the Health Care Reform legislation will impose about $69 billion in penalties for both individual and businesses who don’t meet new mandates to buy health insurance.
• Here’s a really sneaky tax “increase” – if you itemize your tax returns, the deductible for medical expenses will change. You will only be allowed to deduct medical expenses in excess of 10% of your adjusted gross income. Currently that number is 7.5%.
• A medical plan tax that includes several different provisions to increase multiple taxes on things such as cosmetic surgery, cafeteria plans, health insurance providers, production and importation of drugs and medical devices, medical information providing, hospitals and the adjusted gross income floor of medical expenses.
• Doctors and hospitals will receive less compensation than they do now to control revenue streams.
• The Medicare program will see $500 billion in cuts to its program along with the Medicare tax being raised.
• 60% of new enrollees in health care programs will be fully subsidized by you.
Then there’s all those “incentives” laced into the legislation – strangely – only for those Representatives who voted “Yes” for this legislation.
• $300 Million more in Medicare subsidies for Louisiana
• NV, MT, WY, ND, UT all receive $2 billion in Medicare subsides
• Connecticut gets $100 Million to build a hospital
• 11 states total receive 8.5 Billion in Medicaid payments
Even the most casual observer must wonder how a struggling economy, with out-of-control unemployment can bear the burden of so much additional taxation and spending.
President Obama gloated, “This is what change looks like.”
To be fair, I suppose it is possible that Barack Obama never actually said the change he was promising would be positive change, or even change that the American people wanted.
This may be what change looks like, but it is also what bitter partisanship looks like.
Obama promised to reach across the aisle. He never mentioned that once he reached across he was going to sucker punch the Republicans.
Never did I hear Obama promise to ignore the will of the people.
Since last night, Obama, Pelosi and their legion have taken time to grin and pose for the cameras and proclaim the passage of this bill as “historic”. They’ve taken time to pat themselves on the back and to say that this legislation compares to the passage of Medicare, the passage of Social Security and the passage of Civil Rights.
In terms of the monumental impact this law will have on our nation, they are correct to rank it up there with all of those past life-changing pieces of legislation. There is however one incredibly glaring difference. Those milestone pieces of legislation all passed with bi-partisan support.
The only bi-partisanship exhibited in the passing of this legislation was on the side of dissent with more than 30 Democrats crossing over to the Republican side of the aisle to cast their “No” votes. The only Democratic Representative from the state of Texas to vote “No” was Waco’s Chet Edwards.
Obama, Pelosi and the others have suddenly become aware of the words “prayer” and “constitution” and the terms “founding fathers” and to watch them use these words to justify their power grab is insulting. It’s every bit as insulting as the American people being told over and over again that “once you understand it” you’ll be happy to have it.
The condescending attitude from this President and this Congress is unprecedented. The President added to the insult by saying, “We proved that this government — a government of the people and by the people — still works for the people.”
Mr. President that is perhaps your boldest and most condescending lie to date.
56% of the people in this nation opposed this health care reform legislation. Your actions have proven that your words have no meaning and that your government — a government of the politician and for the politician — views the people with absolute disdain.
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It’s certainly hard to do this , when we don’t even know what to be aware of.
The only answer is a different kind of change. The one where the government is reminded of who works for who. That is why we see Patriot Groups all over America now. Americans are fed up and are awakening to a new understanding of what they did when they voted this administration in. I have been told by several interest groups that he let them down and they will not vote for him again. Others are having buyer’s remorse. This bill is a direct violation of the Constitution.
The people will speak in Nov and real change that will actually make us stronger is around the corbner
wi
Full Name: Wayne Berman Title:
Vice-Chair; Finance Co-Chair; Adviser
Over the course of three years, Berman’s lobbying firm was paid $660,000 to lobby on behalf of UnitedHealth subsidiary Americhoice, a managed care HMO providing health insurance to Medicaid, Medicare, and SCHIP recipients. Specifically, according to the lobbying report, they lobbied on Medicaid issues in the Deficit Reduction Act of 2005. [Americhoice Lobbying Reports 2004 – 2007; Americhoice.com]
Berman Also Lobbied For “Absurdly Low” Rates for Medicaid Managed Care Companies to Pay Out of Network Hospitals. Also included in the DRA, and mentioned as a lobbying issue on Berman’s Americhoice lobbying report, was a provision setting rates managed care companies must pay to out-of-network providers — mainly hospital emergency rooms — for care received by Medicaid beneficiaries. Rather than forcing managed care companies to reimburse out-of-network hospitals an amount comparable to network providers, the legislation set the default amount to the state’s “fee-for-service rate,” which often is “absurdly low.” The provision thereby shifted financial responsibility for services to Medicaid beneficiaries from the managed care companies to the hospitals themselves, permitting managed care companies to rake in huge profits, while hospitals incurred added losses. [Modern Healthcare, 1/29/07; Text of S. 1932]
To Save Money, Bill Cut Services to Medicaid Beneficiaries, But Left Managed Care Providers Untouched.
Under the final budget package, substantial Medicaid spending cuts were achieved by imposing new premiums and increased co-payments on Medicaid beneficiaries; some costs were also shifted to the states, who in return were awarded new powers to drop coverage or reduce benefits to certain beneficiaries. In a letter to Senate Majority Leader Bill Frist, the AARP CEO decried the final bill, saying it “protects the pharmaceutical industry, the managed-care industry and other providers at the expense of low-income Medicaid beneficiaries.” [Inside CMS, 12/29/05; Los Angeles Times, 12/22/05; World Markets Analysis, 12/21/05; The Hill, 12/20/05]
Fraud and Abuse Implications of Free Transportation Services Issued: November 17, 2000
Posted: November 24, 2000
Re: OIG Advisory Opinion No. 00-7
Health care providers that offer free goods or services, such as free transportation services, to Federal health care beneficiaries may be subject to civil monetary penalties. In section 1128A(a)(5) of the Act, Congress specifically addressed the issue of providers offering remuneration to Medicare and Medicaid beneficiaries in order to influence their selection of a particular provider by authorizing the imposition of civil monetary penalties against such providers. Moreover, free transportation services may implicate the criminal anti-kickback statute which prohibits offering anything of value to any “person” (including a Federal health care beneficiary) to reward or induce referrals (including self-referrals) for items or services reimbursable under any Federal health care program.(1) Given the overlap between the two statutes, we will begin with some general observations about free transportation services.(2)
First, we recognize that many arrangements involving free transportation have important and beneficial effects on patient care, especially where such arrangements are narrowly tailored to address issues of financial need, limited transportation resources, treatment compliance, or safety.
Second, we also recognize that free transportation services are sometimes an integral part of fraudulent or abusive schemes which lead to inappropriate steering of patients, overutilization, and the provision of medically unnecessary services. Examples of abusive arrangements involving free transportation services include:
Psychiatric facilities offering out-of-state patients free round-trip airline tickets to Florida in order to receive services at their facilities;
Van drivers soliciting, and offering free transportation services to, Medicaid patients for health care providers who compensate the drivers on a per patient or per service basis;
Unscrupulous health care providers offering residents of nursing facilities and other congregate care facilities free transportation services to and from their offices for services that are frequently of questionable necessity;
Hospitals offering patients free limousine services; and
Hospitals offering patients free ambulance services without making individual determinations of financial need.
Third, given their potential for abuse, we evaluate arrangements involving free transportation services on a case-by-case basis. We have identified several risk factors including, but not limited to, the following:
The population to whom free transportation services are offered. While free transportation services offered to “all comers” can implicate section 1128A(a)(5) of the Act and the anti-kickback statute, so can free transportation services offered to select patients or populations. To the extent the services are offered selectively, we evaluate the basis on which the selection is made. For example, an offeror of free transportation services might select individuals based upon one or more of the following criteria: relationship with the offeror (including physician-patient relationships); relationship with other providers (including nursing facility-resident relationships); diagnosis; insurance coverage; geographic location; financial need; or concerns regarding safety or treatment compliance.
The nature or type of free transportation services offered. Expensive transportation services such as limousines, airline tickets, or ambulance transports raise greater concerns.
The geographic area in which free transportation services are offered. Services offered within a provider’s historic service area are less suspect than services offered outside its historic service area.
The availability and affordability of alternate means of transportation.
Whether free transportation services are marketed or advertised and, if so, how.
The type of provider offering the free transportation services. Free transportation services offered by individual or small groups of providers, including physicians, or by freestanding clinics are subject to greater scrutiny. Historically, unscrupulous providers and clinics have offered free transportation services in conjunction with Medicare and Medicaid mills.
Whether the costs of the free transportation services will be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
These factors are not exclusive, and the presence or absence of any one factor is not determinative of whether the OIG would subject parties to sanctions for providing free transportation services to patients.
Fourth, we weigh these factors, as well as other relevant concerns, in assessing the level of risk presented by an arrangement. They are not necessarily determinative or probative of whether an arrangement violates the applicable statutes. The elements required for a violation of the statutes are discussed below.
B. Application of Section 1128A(a)(5) of the Act
Section 1128A(a)(5) of the Act provides for the imposition of civil monetary penalties against any person who:
offers or transfers remuneration to any individual eligible for benefits under [Medicare or a State health care program] that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, under [Medicare or a State health care program].
See also 65 Fed. Reg. 24400, 24416 (April 26, 2000) (to be codified at 42 C.F.R. § 1003.102(b)(13)). Section 1128A(i)(6) of the Act defines “remuneration” for purposes of section 1128A(a)(5) of the Act as including, among other things, “transfers of items or services for free or for other than fair market value.” Unlike the anti-kickback statute, section 1128A(a)(5) of the Act is solely concerned with remuneration offered or transferred to Medicare or State health care program beneficiaries.
Although free transportation services clearly fall within the ambit of the prohibition, legislative history indicates that, in enacting section 1128A(a)(5), Congress did not intend to impose civil monetary penalties against persons offering complimentary local transportation of nominal value. H.R. Conf. Rep. No. 104-736, at 255 (1996). In the preamble to 42 C.F.R. § 1003.102(b)(13), the final rule addressing section 1128A(a)(5) of the Act, we interpreted nominal value for purposes of section 1128A(a)(5) to be no more than $10 per item, or $50 in the aggregate on an annual basis. 65 Fed. Reg. 24400, 24411 (April 26, 2000). Moreover, we theorized that “frequent rendering of items or services to any individual may preclude such items and services from being classified as nominal in value.” Id. at 24407. However, many free transports, including many of those provided under the Arrangement, exceed the nominal value and local service limits.
Notwithstanding, for all of the following reasons, we will not subject Hospital X to civil monetary penalties under section 1128A(a)(5) of the Act in connection with the Arrangement:
There is either limited or no economical means of public transportation in the geographic area where Hospital X provides the free transportation services.
The free transportation services are not advertised and are available only to individuals who have already been referred to, or are being treated at, Hospital X.
The free transportation services are available only if there has been an individualized determination of need (i.e., the patient has no other regular and reliable means of transportation).
The free transportation services are available to all qualified patients who require a course of multiple treatments, subject to available resources. The Arrangement is not limited to, or targeted at, particular profitable treatments or patient populations.
The costs of the free transportation services will not be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
The geographic area within which the free transportation services are offered is limited to Hospital X’s historic primary service area, the size of which is determined in part by its rural location, and other areas that include patients for whom Hospital X is the nearest provider of the prescribed treatments.
Consistent with Hospital X’s not-for-profit mission, the Arrangement provides a benefit to the community by giving elderly and low-income Hospital X patients access to medically necessary, life-prolonging treatments that they may otherwise forego, in whole or in part, because of inadequate transportation.
C. Application of the Anti-Kickback Statute
The anti-kickback statute makes it a criminal offense knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce referrals of items or services reimbursable by any Federal health care program. See section 1128B(b) of the Act. Specifically, the statute provides that:
Whoever knowingly and willfully offers or pays [or solicits or receives] any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person — to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program, shall be guilty of a felony.
Id. Thus, where remuneration is paid purposefully to induce referrals of items or services for which payment may be made by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible “kickback” transaction. For purposes of the anti-kickback statute, “remuneration” includes the transfer of anything of value, in cash or in-kind, directly or indirectly, covertly or overtly.
The statute has been interpreted to cover any arrangement where one purpose of the remuneration was to obtain money for the referral of services or to induce further referrals. United States v. Kats, 871 F.2d 105 (9th Cir. 1989); United States v. Greber, 760 F.2d 68 (3d Cir.), cert. denied, 474 U.S. 988 (1985). Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. Conviction will also lead to automatic exclusion from Federal health care programs, including Medicare and Medicaid. The OIG may also initiate administrative proceedings to exclude persons from Federal and State health care programs or to impose civil monetary penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.
Remuneration from a hospital to a patient that is intended to induce the patient to obtain hospital services implicates the anti-kickback statute. For example, the routine waiver of Medicare Part B coinsurance — a payment obligation required by Federal law — implicates the anti-kickback statute, as would offers of cash or other valuable gifts that are intended to induce patients to order services paid for in whole or in part by a Federal health care program. Free transportation services offered by a hospital to Federal health care program beneficiaries may have monetary value and implicate the anti-kickback statute, if the requisite intent to induce self-referrals is present. Notwithstanding, in the instant case, for all of the reasons set forth above in the analysis of section 1128A(a)(5) of the Act, we will not subject Hospital X to sanctions for violations arising under the Federal anti-kickback statute in connection with the Arrangement.
III. CONCLUSION
For all of the above reasons, and based on the information provided, we conclude that: (i) the OIG will not impose a civil monetary penalty under section 1128A(a)(5) of the Act on Hospital X in connection with the Arrangement, as described and certified in your request letter and supplemental submissions; and (ii) the Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent were present, but that the OIG will not subject Hospital X to sanctions for violations of the anti-kickback statute under sections 1128(b)(7) or 1128A(a)(7) of the Act in connection with the Arrangement, as described and certified in your request letter and supplemental submissions.
IV. LIMITATIONS
The limitations applicable to this opinion include the following:
This advisory opinion is issued only to Hospital X, who is the requestor of this opinion. This advisory opinion has no application, and cannot be relied upon, by any other individual or entity.
This advisory opinion may not be introduced into evidence in any matter involving an entity or individual that is not a requestor to this opinion.
This advisory opinion is applicable only to the statutory provisions specifically noted above. No opinion is herein expressed or implied with respect to the application of any other Federal, state, or local statute, rule, regulation, ordinance, or other law that may be applicable to the Arrangement.
This advisory opinion will not bind or obligate any agency other than the U.S. Department of Health and Human Services.
This advisory opinion is limited in scope to the specific arrangement described in this letter and has no applicability to other arrangements, even those which appear similar in nature or scope.
No opinion is expressed herein regarding the liability of any party under the False Claims Act or other legal authorities for any improper billing, claims submission, cost reporting, or related conduct.
This opinion is also subject to any additional limitations set forth at 42 C.F.R. Part 1008.
The OIG will not proceed against the Requestor with respect to any action that is part of the Arrangement taken in good faith reliance upon this advisory opinion as long as all of the material facts have been fully, completely, and accurately presented, and the Arrangement in practice comports with the information provided. The OIG reserves the right to reconsider the questions and issues raised in this advisory opinion and, where the public interest requires, rescind, modify or terminate this opinion. In the event that this advisory opinion is modified or terminated, the OIG will not proceed against the Requestor with respect to any action taken in good faith reliance upon this advisory opinion, where all of the relevant facts were fully, completely, and accurately presented and where such action was promptly discontinued upon notification of the modification or termination of this advisory opinion. An advisory opinion may be rescinded only if the relevant and material facts have not been fully, completely and accurately disclosed to the OIG.
Sincerely,
/s/
D. McCarty Thornton
Chief Counsel to the Inspector General
FOOTNOTES:
1. Because both the criminal and administrative sanctions related to the anti-kickback implications of the Arrangement are based on violations of the anti-kickback statute, the analysis for purposes of this advisory opinion is the same under both.
2. Providers offering transportation services to beneficiaries at a price that is below fair market