healthcare

Dec. 22 (UPI) — The former CEO of a healthcare software company in Arizona was sentenced to 15 years in prison and ordered to pay more than $452 million in restitution for conspiring to defraud Medicare for $1 billion, the U.S. Department of Justice said Monday.

Gary Cox, 79, of Maricopa County, was found guilty in June of healthcare fraud in which he generated false doctors’ orders to support fraudulent claims for various medical items.

He was sentenced Friday in the Southern District of Florida.

“This just sentence is the result of one of the largest telemarketing Medicare fraud cases ever tried to verdict,” Acting Assistant Attorney General Matthew R. Galeotti of the Justice Department’s Criminal Division said in a statement. “Telemedicine scammers who use junk mailers, spam calls and the internet to target senior citizens steal taxpayer money and harm vulnerable populations. The Criminal Division will continue dedicating substantial resources to the fight against telemedicine and medical equipment frauds that drain our health care benefit programs.”

Cox was convicted of conspiracy to commit healthcare fraud and wire fraud, three counts of healthcare fraud, conspiracy to pay and receive healthcare kickbacks, and conspiracy to defraud the United States and make false statements in connection with healthcare matters.

Cox was the CEO of Power Mobility Doctor Rx, LLC.

Prosecutors say Cox and his co-conspirators targeted several hundred thousand Medicare beneficiaries who provided personally identifiable information and agreed to accept medically unnecessary orthotic braces, pain creams and other items through misleading mailers, television advertisements and calls from offshore call centers, the Justice Department said.

Cox connected pharmacies, durable medical equipment suppliers and marketers with telemedicine companies to accept illegal kickbacks and bribes in exchange for signed doctors’ orders transmitted using the DMERx platform.

Prosecutors said DMERx falsely said that a doctor had examined and treated the Medicare beneficiaries when, in fact, purported telemedicine companies paid doctors to sign the orders without regard to medical necessity. It was based on a brief telephone call with the beneficiary or no interaction with the beneficiary, the Justice Department said.

These doctors’ orders billed Medicare and other insurers more than $1 billion with Medicare and the insurers paying more than $360 million based on these claims.

The scheme was concealed through sham contracts and elimination from doctors’ orders in which one co-conspirator described as “dangerous words” that might cause Medicare to audit the scheme’s DME suppliers.

“This sentence sends a clear message: Those who exploit telemedicine to prey on seniors and steal from taxpayer-funded health care programs will be held accountable,” said Christian J. Schrank, deputy inspector general for investigations of the U.S. Department of Health and Human Services.

“This scheme was a massive betrayal of trust, built on deception and greed. Our investigators, working with law enforcement partners, dismantled this billion-dollar fraud operation that targeted vulnerable patients and undermined the integrity of Medicare. We will not relent in our mission to protect the public and safeguard Medicare and other federal health care programs from fraud, waste, and abuse.”

Before his sentencing, friends of the defendant submitted letters to the judge vouching for Cox’s good character.

“It is my belief, based on all my life experiences both good and bad that Gary is not a person that would take advantage of or cheat another,” one letter said.

Since March 2007, the Justice Department’s Fraud Section, operating nine strike forces in 27 federal districts, has charged more than 5,800 defendants, who collectively have billed federal healthcare programs and private insurers more than $30 billion.

“Together with our partners, the FBI will aggressively pursue those who defraud taxpayer-funded health care programs,” Rebecca Day, acting assistant director of the FBI’s Criminal Investigative Division, said. “Programs like Medicare are intended to help the most vulnerable among us, and fraud schemes like the one orchestrated by the defendant can jeopardize the delivery of critical care to those who need it the most.”

Approximately 69.4 million Americans are enrolled in the federal health insurance, which is primarily for people aged 65 and older. It also covers younger people with long-term disability, end-stage renal disease or ALS.

Medicare fraud, mistakes and abuse cost the program an estimated $60 billion annually.

“Medicare numbers are more valuable than Social Security numbers because if they have all the right documentation, the Medicare claim has to go through, there are rules and regulations around that,” Nancy Moore, director of Indiana Senior Medicare Patrol, told WRTV-TV in June.

“One of the best ways to look out for fraud is to read your summary notices, your EOB if you’re on Medicare Advantage, or your Medicare summary notice. If you notice a charge for something you never received or didn’t need. That’s when you should call us to report it.”

Consumers can also report suspected medical identity theft to the Health & Human Services fraud hotline at 800-447-8477 (800-HHS-TIPS) or the National Insurance Crime Bureau at 800-835-6422.

Folks, who was supposed to be watching grandpa last night? Because he got out, got on TV and … It. Was. Not. Good.

For 18 long minutes Wednesday evening, we were subjected to a rant by President Trump that predictably careened from immigrants (bad) to jobs (good), rarely slowing down for reality. But jumbled between the vitriol and venom was a vision of American healthcare that would have horror villainess M3GAN shaking in her Mary Janes — a vision that we all should be afraid of because it would take us back to a dark era when insurance couldn’t be counted on.

Trump’s remarks offered only a sketchy outline, per usual, in which the costs of health insurance premiums may be lower — but it will be because the coverage is terrible. Yes, you’ll save money. But so what? A cheap car without wheels is not a deal.

“The money should go to the people,” Trump said of his sort-of plan.

The money he vaguely was alluding to is the government subsidies that make insurance under the Affordable Care Act affordable. After antics and a mini-rebellion by four Republicans also on Wednesday, Congress basically failed to do anything meaningful on healthcare — pretty much ensuring those subsidies will disappear with the New Year.

Starting in January, premiums for too many people are going to leap skyward without the subsidies, jumping by an average of $1,016 according to the health policy research group KFF.

That’s bad enough. But Trump would like to make it worse.

The Affordable Care Act is about much more than those subsidies. Before it took effect in 2014, insurance companies in many states could deny coverage for preexisting conditions. This didn’t have to be big-ticket stuff like cancer. A kid with asthma? A mom with colitis? Those were the kind of routine but chronic problems that prevented millions from obtaining insurance — and therefore care.

Obamacare required that policies sold on its exchange did not discriminate. In addition, the ACA required plans to limit out-of-pocket costs and end lifetime dollar caps, and provide a baseline of coverage that included essentials such as maternity care. Those standards put pressure on all plans to include more, even those offered through large employers.

Trump would like to undo much of that. He instead wants to fall back on the stunt he loves the most — send a check!

What he is suggesting by sending subsidy money directly to consumers also most likely would open the market to plans without the regulation of the ACA. So yes, small businesses or even groups of individuals might be able to band together to buy insurance, but there likely would be fewer rules about what — or whom — it has to cover.

Most people aren’t savvy or careful enough to understand the limitations of their insurance before it matters. So it has a $2-million lifetime cap? That sounds like a lot until your kid needs a treatment that eats through that in a couple of months. Then what?

Trump suggested people pay for it themselves, out of health savings accounts funded by that subsidy check sent directly to taxpayers. Because that definitely will work, and people won’t spend the money on groceries or rent, and what they do save certainly will cover any medical expenses.

“You’ll get much better healthcare at a much lower price,” Trump claimed Wednesday. “The only losers will be insurance companies that have gotten rich, and the Democrat Party, which is totally controlled by those same insurance companies. They will not be happy, but that’s OK with me because you, the people, are finally going to be getting great healthcare at a lower cost.”

He then bizarrely tried to blame the expiring subsidies on Democrats.

Democrats “are demanding those increases and it’s their fault,” he said. “It is not the Republicans’ fault. It’s the Democrats’ fault. It’s the Unaffordable Care Act, and everybody knew it.”

It seems like Trump just wants to lower costs at the expense of quality. Here’s where I take issue with the Democrats. I am not here to defend insurance companies or our healthcare system. Both clearly need reform.

But why are the Democrats failing to explain what “The money should go to the people” will mean?

I get that affordability is the message, and as someone who bought both a steak and a carton of milk this week, I understand just how powerful that issue is.

Still, everyone, Democrat or Republican, wants decent healthcare they can afford, and the peace of mind of knowing if something terrible happens, they will have access to help. There is no American who gladly would pay for insurance each month, no matter how low the premium, that is going to leave them without care when they or their loved ones need it most.

Grandpa Trump doesn’t have this worry, since he has the best healthcare our tax dollars can buy.

But when he promises to send a check instead of providing governance and regulation of one of the most critical purchases in our lives, the message is sickening: My victory in exchange for your well-being.

An expanded federal healthcare subsidy that grew out of the pandemic looks all but certain to expire on December 31, as Republican leaders in the United States faced a rebellion from within their own ranks.

On Wednesday, four centrist Republicans in the House of Representatives broke with their party’s leadership to support a Democratic-backed extension for the healthcare subsidies under the Affordable Care Act (ACA), sometimes called “Obamacare”.

By a vote of 204 to 203, the House voted to stop the last-minute move by Democrats, aided by four Republicans, to force quick votes on a three-year extension of the Affordable Care Act subsidy.

Democrats loudly protested, accusing Republican leadership of gavelling an end to the vote prematurely while some members were still trying to vote.

“That’s outrageous,” Democratic Representative Jim McGovern of Massachusetts yelled at Republican leadership.

Some of the 24 million Americans who buy their health insurance through the ACA programme could face sharply higher costs beginning on January 1 without action by Congress.

Twenty-six House members had not yet voted – and some were actively trying to do so – when the House Republican leadership gavelled the vote closed on Wednesday. It is rare but not unprecedented for House leadership to cut a contested vote short.

Democratic Representative Rosa DeLauro of Connecticut said the decision prevented some Democrats from voting.

“Listen, it’s playing games when people’s lives are at stake,” DeLauro said. “They jettisoned it.”

It was the latest episode of congressional discord over the subsidies, which are slated to expire at the end of the year.

The vote also offered another key test to the Republican leadership of House Speaker Mike Johnson. Normally, Johnson determines which bills to bring to a House vote, but recently, his power has been circumvented by a series of “discharge petitions”, wherein a majority of representatives sign a petition to force a vote.

In a series of quickfire manoeuvres on Wednesday, Democrats resorted to one such discharge petition to force a vote on the healthcare subsidies in the new year.

They were joined by the four centrist Republicans: Mike Lawler of New York and Brian Fitzpatrick, Robert Bresnahan and Ryan MacKenzie of Pennsylvania.

The Democratic proposal would see the subsidies extended for three years.

But Republicans have largely rallied around their own proposal, a bill called the Lower Health Care Premiums for All Americans Act. It would reduce some insurance premiums, though critics argue it would raise others, and it would also reduce healthcare subsidies overall.

The nonpartisan Congressional Budget Office (CBO) on Tuesday said the legislation would decrease the number of people with health insurance by an average of 100,000 per year through 2035.

Its money-saving provisions would reduce federal deficits by $35.6bn, the CBO said.

Republicans have a narrow 220-seat majority in the 435-seat House of Representatives, and Democrats are hoping to flip the chamber to their control in the 2026 midterm elections.

Three of the four Republicans who sided with the Democrats over the discharge petition are from the swing state of Pennsylvania, where voters could lean right or left.

Affordability has emerged as a central question ahead of the 2026 midterms.

Even if the Republican-controlled House manages to pass a healthcare bill this week, it is unlikely to be taken up by the Senate before Congress begins a looming end-of-year recess that would stop legislative action until January 5.

By then, millions of Americans will be looking at significantly more expensive health insurance premiums that could prompt some to go without coverage.

Wednesday’s House floor battle could embolden Democrats and some Republicans to revisit the issue in January, even though higher premiums will already be in the pipeline.

Referring to the House debate, moderate Republican Senator Lisa Murkowski told reporters: “I think that that will help prompt a response here in the Senate after the first of the new year, and I’m looking forward to that.”

The ACA subsidies were a major point of friction earlier this year as well, during the historic 43-day government shutdown.

Democrats had hoped to extend the subsidies during the debate over government spending, but Republican leaders refused to take up the issue until a continuing budget resolution was passed first.

BIRMINGHAM, Ala. — Former U.S. Sen. Doug Jones, the last Democrat to hold statewide office in Alabama, kicked off his campaign for governor Friday, saying voters deserve a choice and a leader who will put aside divisions to address the state’s pressing needs.

“With your help we can finish what we began. We can build the Alabama we’ve always deserved,” Jones told a packed crowd at a Birmingham campaign rally featuring musician Jason Isbell.

He said the state has urgent economic, healthcare and educational issues that are not being addressed by those in public office.

The campaign kickoff came on the eighth anniversary of Jones’ stunning 2017 Senate win over Republican Roy Moore, and Jones said Alabama proved back then that it can defy “simplified labels of red and blue.”

“You stood up and you said something simple but powerful: We can do better,” Jones said. “You said with your votes that our values, Alabama values, are more important than any political party, any personality, any prepackaged ideology.”

His entry into the race sets up a possible rematch with Republican Sen. Tommy Tuberville, who defeated Jones by 20 points in the 2020 Senate race and is also now running for governor. Both parties will have primaries in May before the November election.

Before running for office, Jones, a lawyer and former U.S. attorney, was best known for prosecuting two Ku Klux Klansmen responsible for Birmingham’s infamous 1963 church bombing.

In an interview with the Associated Press, Jones said families are having a hard time with things like healthcare, energy bills and making ends meet.

“People are struggling,” he said. “They are hurting.”

Jones used part of his speech to describe his agenda if elected governor. He said it is time for Alabama to join most states in establishing a state lottery and expanding Medicaid. Expanding Medicaid, he said, would protect rural hospitals from closure and provide healthcare coverage to working families and others who need it.

He criticized Tuberville’s opposition to extending Affordable Care Act subsidies in the Senate. Jones said many Alabama families depend on those subsidies to buy health insurance “to keep their families healthy.”

Alabama has not elected a Democratic governor since Don Siegelman in 1998.

When Tuberville ousted Jones in 2020, the Democrat won about 40% of the vote, which has been the ceiling for Alabama Democrats in recent statewide races.

Retired political science professor Jess Brown said Jones lost in 2020 despite being a well-funded incumbent, and that’s a sign that he faces an uphill battle in 2026.

“Based on what I know today, at this juncture of the campaign, I would say that Doug Jones, who’s a very talented and bright man, is politically the walking dead,” Brown said.

Jones acknowledged being the underdog and said his decision to run stemmed in part from a desire that Tuberville not coast into office unchallenged.

Jones pointed to recent Democratic victories in Georgia, Mississippi and other red states as cause for optimism.

Tuberville, who formerly led the football program at Auburn University, had “no record except as a football coach” when he first ran, Jones said. And “now there are five years of being a United States senator. There are five years of embarrassing the state.”

Jones continued to question Tuberville’s residency, saying he “doesn’t even live in Alabama, and if he does, then prove me wrong.” Tuberville has a beach house in Walton County, Fla., but has repeatedly said Auburn is his home.

Tuberville’s campaign did not immediately respond to a request for comment but has previously noted his commanding defeat of Jones five years ago. The Republican senator spent part of Friday with Defense Secretary Pete Hegseth in Huntsville to mark the official relocation of U.S. Space Command from Colorado to Alabama.

Jones’ 2017 victory renewed the hopes, at least temporarily, of Democratic voters in the Deep South state. Those gathered to hear him Friday cheered his return to the political stage.

“I’m just glad that there’s somebody sensible getting in the race,” Angela Hornbuckle said. “He proved that he could do it as a senator.”

Chandler writes for the Associated Press.

Dec. 11 (UPI) — The Senate failed to approve either of two competing healthcare plans meant to address healthcare costs likely to rise in the new year with the expiration of Affordable Care Act tax credits.

Democrats and Republicans each put forth their own healthcare plans, but neither mustered the 60 votes needed to overcome the Senate’s filibuster rule with identical 51-48 vote totals, NBC News and The Hill reported.

Each proposal mostly received party-line support, with only Sen. Rand Paul, R-Ky. voting against the GOP proposal, which all Senate Democrats also opposed.

Senate Democrats received some GOP support for their proposal, with Sens. Susan Collins, R-Maine, Josh Hawley, R-Mo., Lisa Murkowski, R-Alaska, and Dan Sullivan, R-Alaska, voting in favor.

Sen. Steve Daines, R-Mont., did not cast a vote for or against either measure.

The Democrats’ plan included a three-year extension of enhanced ACA subsidies beyond the Jan. 1 expiration date. The proposal would also limit health insurance premiums under the ACA to 8.5% of the policyholders’ incomes.

The enhanced subsidies were put in place during the COVID-19 pandemic as part of the 2021 American Rescue Plan.

To pass, Democrats needed at least 13 Republicans to vote in favor of the plan.

The expiring subsidies were the crux of a six-week government shutdown this fall. Democrats refused to vote in favor of a House Republican-drafted stopgap funding measure without including language that would see the subsidies extended beyond December.

Without the subsidies, healthcare premiums through the ACA were forecast to more than double in some cases. The Congressional Budget Office projects about 3.8 million will drop coverage annually over the next eight years without the additional subsidies. In 2025, a record 24 million Americans got their health insurance through the healthcare marketplace.

“We have 21 days until Jan.1,” Senate Democratic leader Chuck Schumer said on the Senate floor Wednesday. “After that, people’s healthcare bills will start going through the roof. Double, triple, even more.

“There is only one way to avoid all of this. The only realistic path left is what Democrats are proposing — a clean, direct extension of this urgent tax credit.”

Republicans, however, refused to consider the subsidies as part of the continuing resolution. Ultimately, Republicans agreed to consider a separate healthcare vote as a tradeoff to reopening the government.

The Republican plan, unveiled Tuesday by Sens. Bill Cassidy and Mike Crapo, doesn’t extend the subsidies but provides $1,500 health savings accounts for those earning less than 700% of the poverty level.”

“It delivers the benefit directly to the patient, not to the insurance company, and it does it in a way that actually saves money to the taxpayer,” Senate Republican leader John Thune said.

He described the Democrats’ plan as a “partisan messaging exercise” and called the idea that it would lower healthcare costs a “tour of fantasy land,” according to ABC News.

WASHINGTON — The Senate on Thursday rejected legislation to extend Affordable Care Act tax credits, essentially guaranteeing that millions of Americans will see a steep rise in costs at the beginning of the year.

Senators rejected a Democratic bill to extend the subsidies for three years and a Republican alternative that would have created new health savings accounts — an unceremonious end to a monthslong effort by Democrats to prevent the COVID-19-era subsidies from expiring on Jan. 1.

Ahead of the votes, Senate Democratic Leader Chuck Schumer of New York warned Republicans that if they did not vote to extend the tax credits, “there won’t be another chance to act,” before premiums rise for many people who buy insurance off the ACA marketplaces.

“Let’s avert a disaster,” Schumer said. “The American people are watching.”

Republicans have argued that Affordable Care Act plans are too expensive and need to be overhauled. The health savings accounts in the GOP bill would give money directly to consumers instead of to insurance companies, an idea that has been echoed by President Trump. But Democrats immediately rejected the plan, saying that the accounts wouldn’t be enough to cover costs for most consumers.

Some Republicans have pushed their colleagues to extend the credits, including Sen. Thom Tillis of North Carolina, who said they should vote for a short-term extension so they can find agreement on the issue next year. “It’s too complicated and too difficult to get done in the limited time that we have left,” Tillis said Wednesday.

But despite the bipartisan desire to continue the credits, Republicans and Democrats have never engaged in meaningful or high-level negotiations on a solution, even after a small group of centrist Democrats struck a deal with Republicans last month to end the 43-day government shutdown in exchange for a vote on extending the ACA subsidies. Most Democratic lawmakers opposed the move as many Republicans made clear that they wanted the tax credits to expire.

The deal raised hopes for bipartisan compromise on healthcare. But that quickly faded with a lack of any real bipartisan talks.

The dueling Senate votes are the latest political messaging exercise in a Congress that has operated almost entirely on partisan terms, as Republicans pushed through a massive tax and spending cuts bill this summer using budget maneuvers that eliminated the need for Democratic votes. They also tweaked Senate rules to push past a Democratic blockade of all of Trump’s nominees.

An intractable issue

The votes were also the latest failed salvo in the debate over the Affordable Care Act, President Obama’s signature law that Democrats passed along party lines in 2010 to expand access to insurance coverage.

Republicans have tried unsuccessfully since then to repeal or overhaul the law, arguing that healthcare is still too expensive. But they have struggled to find an alternative. In the meantime, Democrats have made the policy a central political issue in several elections, betting that the millions of people who buy healthcare on the government marketplaces want to keep their coverage.

“When people’s monthly payments spike next year, they’ll know it was Republicans that made it happen,” Schumer said in November, while making clear that Democrats would not seek compromise.

Even if they view it as a political win, the failed votes are a loss for Democrats who demanded an extension of the benefits as they forced a government shutdown for six weeks in October and November — and for the millions of people facing premium increases on Jan. 1.

Maine Sen. Angus King, an independent who caucuses with Democrats, said the group tried to negotiate with Republicans after the shutdown ended. But, he said, the talks became unproductive when Republicans demanded language adding new limits for abortion coverage that were a “red line” for Democrats. He said Republicans were going to “own these increases.”

A plethora of plans, but little agreement

Republicans have used the looming expiration of the subsidies to renew their longstanding criticisms of the ACA, also called Obamacare, and to try, once more, to agree on what should be done.

Thune announced earlier this week that the GOP conference had decided to vote on the bill led by Louisiana Sen. Bill Cassidy, the chairman of the Senate Health, Labor, Education and Pensions Committee, and Idaho Sen. Mike Crapo, the chairman of the Senate Finance Committee, even as several Republican senators proposed alternate ideas.

In the House, Speaker Mike Johnson (R-La.) has promised a vote next week. Republicans weighed different options in a conference meeting on Wednesday, with no apparent consensus.

Republican moderates in the House who could have competitive reelection bids next year are pushing Johnson to find a way to extend the subsidies. But more conservative members want to see the law overhauled.

Rep. Kevin Kiley (R-Rocklin) has pushed for a temporary extension, which he said could be an opening to take further steps on healthcare.

If they fail to act and healthcare costs go up, the approval rating for Congress “will get even lower,” Kiley said.

Jalonick writes for the Associated Press. AP writers Kevin Freking and Joey Cappelletti contributed to this report.