Health Insurance Fraud conducted by HMO's

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Subj: Terminate ALL HMO Contracts immediately
Date: 9/15/2005 3:53:45 PM Eastern Daylight Time
From: LawISAmootIssue

No Accountability
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By Kimberly Kimball 10073 Bryce Road Kenokee Twp MI 48006
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Please help stop Health Insurance Fraud conducted by HMO's by Terminating any and ALL HMO Contracting. The reason Health Insurance is so Costly has Nothing to do with providing covered services and everything to do with DENYING Covered Services.
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Federal Contractors who sell HMO Services to Other Companies are using the HMO Government Grievance Procedures to Allow the killing of Retired HMO Beneficiaries by automatic denial of posthospital care for criminal conversion into Other Government Programs. ( Our Health Care Crisis ).
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Since 1999 I have reporting Mass Hospital Insurance Fraud targeting Hospitalized Retired Federal Employee Health Beneficiaries and Law Enforcement REFUSES to protect them from criminal felony federal health care offences - Anti Dumping & Anti Kickback Violations that results in serious bodily injury and death.
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Hospitalized Elderly HMO Beneficiaries are unable to conduct the HMO Government Grievance Procedures ( takes 4 years to complete ) enacted against them thru Hospital Discharge Procedures to deny posthospital care.
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1999 RULES & REGULATIONS Part IV DHHS OIG 42 CFR Part 1001 . Federal Health care Programs: ( FEHBP ) . Fraud & Abuse Anti Kickback Statutes Sect 1128B(b) of the Social Security Act provides criminal penalties for individuals or entities that knowingly & willfully offer, pay, solicit, or recieve renumeration to induce the referral of business reimbursable under a Federal Health Care Program ( including Medicare & Medicaid ). Section 2 of the Medicare and Medicaid Patient & PROGRAM PROTECTION ACT of 1987 ( MMPPPA )
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Carrier subject to prosecution under section 1001, title 18, United States Code.
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Subj: Re: Health Alliance Insurance Fraud
Date: 2/21/2003 5:07:41 PM Eastern Standard Time
From: [e-mail] (Senator Debbie Stabenow) To: [e-mail]
February 21, 2003
Kimberly Kimball
10073 Bryce Road
Avoca, Michigan 48006
Thank you . . .
. . for contacting me about ( OPM FEHBP ) insurance & Medicaid ( kickback ) fraud committed by Health Alliance Plan. I appreciate that you have taken the time to
communicate your views and concerns with me.
I understand your concern about this issue. Should related legislation
come before the U.S. Senate for a vote, I will keep your views in mind,
and share your thoughts on this issue with my colleagues who serve on the
Health, Education, Labor and Pensions Committee.
Thank you again for contacting me. Please feel free to contact me
whenever I can be of assistance to you or your family.
Sincerely,
Debbie Stabenow
United States Senator
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State of Michigan has been Allowing Federal HMO Contractors to dump Elderly HMO beneficiaries into State Medicaid ( criminal kickback conversions ) by Automatic Denial of Posthospital Care.
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According to the Detroit News, Between 1999 & 2001 Michigan's Medicaid clientele ballooned to 1.25 million from 1 million, at a cost of approximately $6,000 on each Medicaid Reciepent.
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According to Vernon Smith, " a health care expert " who attended - Previous Attorney General MI, ( now ) Governor Jennifer Granholms Summit, he stated the Biggest Factor responsible for raising Medicaid spending is Enrollment. ( Retired FEHBP forced to apply for Medicaid because of HMO Hospital Dumping ( kickback fraud ).
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The Detroit News stated according to Paul Rienhart " a Medicaid Expert " in The State Budget Office of Michigan, says
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Medicaid will consume 32 % of the General Fund budget by 2004.
Medicaid consumed 8% of Michigan's General Funds in 1998.
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In 1999 mass Hospital DHHS dumping into Medicaid of OPM Retired Federal Employee Health Beneficiaries began.
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Nursing Home Nightmare
Couple Stands Accused of Negligent Homicide in deaths of 34 Elderly Patients ( Sept 14 05 ) but HMO's can deny Covered services causing death with NO Accountability.
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Title 18 US Code section 286 Conspiracy to defraud the Government with respect to claims . WHOEVER enters into any agreement, combination, or conspiracy to defraud the United States, or any department or agency thereof, by obtaining or aiding to obtain ...................................
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DHHS. Hospital DHHS Workers enact the HMO Grievance Procedure against Retired FEHBP to induce forfiture for criminal conversion into Other ( Medicaid ) Government Programs.
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TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS .Subpart A--General Provisions Sec. 417.1 Definitions. 417.2 Basis and scope. Subpart B-- Qualified Health Maintenance Organizations: " Services " (g) Grievance procedures. . (h) Special rules: Enrollees under the Federal employee health benefits program (FEHBP). An HMO that accepts enrollees under the FEHBP (Chapter 89 of title 5 of the U.S.C.) may obtain and retain Federal qualification if, for its other enrollees, it complies with the requirements of section 1301(b) and 1301(c) of the PHS Act and implementing regulations in this subpart D ( Subpart D--Requirements for Coverage of Posthospital SNF Care )( Subpart D--Nondiscrimination in Federally Assisted Programs in the Office of Personnel Management ) and subparts B and C of this .
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...... And to further conceal HMO Hospital Insurance fraud against OPM Retired FEHBP for criminal conversion into Other Government Programs: ( HCFA - Medicaid )
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OPM. Health Insurance Contracting Divisions ( FEHBP ) conceal the Hospital dumping for felony Medicaid kickback conversions by criminal use of Public Policy - DHHS HMO Grievance Procedures. Obstruction of Justice regarding felony federal health care offences against FEHBP beneficiaries of OPM.
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CITE: 5CFR890.105 PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM - OPM - Sec. 890.105 Filing claims for payment or service. . If the carrier ( HMO ) denies a claim (or a portion of a claim - [ posthospital extended care services ] ), the covered individual may ask the carrier ( HMO ) to reconsider its denial. If the carrier affirms its denial or fails to respond as required by paragraph (c) of this section, the covered individual * may ask * OPM to review the claim. . A covered individual * must exhaust both * the carrier ( DHHS - HMO- service-grievance procedure ) and OPM review processes specified in this section before seeking judicial review of the denied claim. . (2) This section applies to covered individuals .
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Note: Elderly Hospitalized FEHB Beneficiaries are NOT Able to conduct these procedures used to deny them Posthospital care ( which took me 4 years to complete - including filing in Federal Court for Judicial Review Per HMO Government Grievance Procedures ) which results in the targeted Victims serious bodily injury or death - makeing them perfect targets for fraudulent insurance acts - anti dumping / anti kickback violations Felony Offence.
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Crime Victims and Civil Rights denied - Judicial Review Denied !!!
HMO Covered Benefits DENIED !
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UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF MICHIGAN
Chambers of Honorable George Caram Steeh
United States District Judge
Theodore Levin United States Courthouse
231 West Lafayette Blvd. - room 235
Detroit, Michigan 48226
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Case # 03-75161 ..............8 Jan 04 Judicial Review DENIED & DISMISSED as ' without merrit & frivolous '
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Title 28 U.S.C. § 1361. Action to compel an officer of the United States to perform his duty. The district courts shall have original jurisdiction of any action in the nature of mandamus to compel an officer or employee of the United States or any agency thereof to perform a duty owed to the plaintiff.
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FBI: Criminal Cases - Health Care Fraud
FBI: Economic Crimes Unit
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.....................the payment or Allowance of any false, fictitious or fraudulent claim, shall be fined under this title or imprisoned not more than 10 years, or BOTH.
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Title 18 U.S.C. 4. Misprision of felony.
Whoever, having knowledge of the actual commission of a felony cognizable by a court of the United States, conceals and does not as soon as possible make known the same to some judge or other person in civil or military authority under the United States, shall be fined under this title or imprisoned not more than three years, or both.
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18 USC Sec. 24 01/02/01-EXPCITE- TITLE 18 - CRIMES AND CRIMINAL PROCEDURE PART I - CRIMES CHAPTER 1 - GENERAL PROVISIONS-HEAD- Sec. 24. Definitions relating to Federal health care offense-STATUTE-
(a) As used in this title, the term ''Federal health care offense'' means a violation of, or a criminal conspiracy to violate- (1) section 669,1035 - reads - False statements relating to health care matters, 1347, or 1518 - reads - obstruction of criminal investigations of health care offences, of this title; ( 2) section 287, 371, 664, 666, 1001- anti kickback violations, 1027, 1341, 1343, or 1954 of this title, if the violation or conspiracy relates to a health care benefit program. (b) As used in this
title, the term ''health care benefit program'' means any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual, and includes any individual or entity who is providing a medical benefit, item, or service ( OPM & DHHS HMO Grievance Procedures )for which payment may be made under the plan or contract.-SOURCE- (Added Pub. L. 104-191, title II, Sec. 241(a), Aug. 21, 1996, 110 Stat. 2016.)-SECREF- SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in sections 669, 1035 of this title; title 42 section 1395i.
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FEHB OPM employee Below is refusing to report FEHB Hospital Insurance Fraud that resulted in Death of a Federal Beneficiary to proper authorities. FEHB OPM Employees are assisting in Hospital Dumping by refering FELONY offences into the HMO Grievance Procedures. Title 18 - crime - Obstruction of Justice.
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OPM Appeal Process: 3/3/00
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HMO Grievance Procedures enacted by Hospital DHHS, began 12 April 1999 during Victims Hospitalization - discharge procedures - felony Medicaid kickback fraud.
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Subj: RE: more details
Date: 3/3/00 12:23:10 PM Eastern Standard Time
From: [e-mail] (FEHB Internet Mailbox)
To: [e-mail] ('[e-mail]')
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I am sorry about what happened to your mother. It's so hard to watch
someone we love suffer, and if we feel the person isn't getting the proper
medical care, it makes it so much worse.
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You have a couple options for addressing your concerns.
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- Administrative Fraud ( below ) used to conceal FEHBP Fraud & HMO Abuse -
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The first option is to go through the health plan. As you know, benefits
for extended care/skilled nursing facilities are limited. <~~ LIE it is Illegal / felony, to deny Covered ' Hospital Extended Care Benefits " - Services, for criminal kickback Medicaid Conversions.
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Michigan Compiled Laws: Complete through PA ( public act ) 297 of 2000 PUBLIC HEALTH CODE ( EXCERPT ) ACT 368 OF 1978 . 333.5659 Life Insurer, health insurer, or health care payment or benefits plan; Prohibited Acts. ( b ) LIMIT the amount of coverage or benefits available to a terminally ill patient within the scope and level of coverage or benefits of an existing policy, certificate, or contract.
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But if you feel that the care your mother was receiving should have been covered, based on the description in the plan's brochure, you can file a disputed claim. The process is spelled out in the brochure. You must first request a reconsideration from the plan; they may overturn their decision on appeal. If they uphold their decision, your next level of appeal is OPM.
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Health Alliance Plan - FEHB ( Federal Employee Health Benefits Program RI 73-015 .... page 15 ) . " Hospital Extended Care Benefits " The Plan provides a comprehensive range of benefits when skilled nursing care is necessary & confinement in a skilled nursing facility is medically appropriate as determined by a plan doctor. The Plan pays for up to 730 days ( 2 years ) each continuous period of confinement or for sucessive periods seperated by less than 60 days.
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This 730 days period will be reduced by 2 days for every inpatient Hospital day Prior to Admission into a skilled nursing facility. ( Hospital Transfers )
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A new period of 730 days will begin after at least 60 days have elapsed from the last date of discharge. You pay nothing. All necessary services are Covered,
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including: ::::::: bed, board & general nursing care ::::::: drugs, biologicals, supplies & EQUIPEMENT ordinarily provided or arranged by the skilled nursing facility when perscribed by a Plan Doctor .
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Disputed Claim: Automatic denial of Hospital Extended Care Services ( OPM Contract terminated by the HMO on 5 May 99 causing onset of death as threatened ( 2 weeks ). Victim was discharged to go home and was on a girney in the hallway when family arrived at 9 am for a " care confrence ". family moved victim to Private Pay area and the Hospital Extended Care Facility began Billing the victim's family for illegal termination of posthospital services. Victim suffered in sever pain untill death on 8 May 1999 from Urinary Sepsis, Gastro Intestinal Hemoraging & C Deffile Colitis.
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Subj: Skilled Nursing Facility Coverage <~ deception of Hospital Extended Care Benefits '
Date: 4/23/99 8:19:16 PM !!!First Boot!!!
From:[e-mail] (Member Services Web)
To: [e-mail]
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Ms. Kimball,
Thank you once again for contacting the <~ Government HMO Grievance Procedure
Member Services Web. Upon review of the
referral to Nightengale East Nursing Center, <--- deception: Hospital transfer
we have found that Mrs.Rupert will be
referred to Nightengale for a total of two <---illegally limitting contracted benefits
weeks for family training for maintenance of
her feeding tube. This family training is
considered to be basic care according to <--- 42PHC 409.32 & 33 Hospital Requirements
HAP criteria. Although the skilled nursing
facility benefit is for up to 730 days, HAP <---deception-Hospital Extended Care Benefit,
criteria require that the care must be skilled. <----Mattie of HAP, approved skilled nursing with hospital SW prior to Hospital discharge on 20 April 1999.
Because Mrs.Rupert is recieving basic and
NOT skilled care, she does not meet the <---- false claim fraud ( intent to harm )
criteria for the maxium benefit.
If you would like to speak to someone
directly regarding Mrs.Rupert's care, you
are more than welcome to call HAP at
1-800-422-4641 and ask for Mattie Ogburn.
Ms.Ogburn has spoken with Mr.Rupert and
is handling your Mother's case.
Member Services Web
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Automatic denial of Hospital Insurance - Requirements for Posthospital skilled nursing care services. Hospital dumping.
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The second option, if you really believe that fraud is involved, is to file
a complaint with our Inspector General's office. They investigate fraud
complaints. You may either call the health care fraud hotline
(202-418-3300) or write to:
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U.S. Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
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Again, I'm sorry to hear about your mother's death.
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Karen Leibach
Insurance Policy and Information Division
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U.S. Office of Personnel Management
Office of the Inspector General Fraud Hotline
Joseph Frech investigator
dtd: 9 may 2002
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" The matters discribed in your letter are not within the jurisdiction of this office. The OIG had also recieved information regarding your case in September 2000. At that time we determined that the Health Benefits Contracts Division has sole jurisdiction over your complaint. The decision made by the contracts division is final and the OIG will NOT Investigate. "
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500.4503 Fraudulent insurance acts. [M.S.A. 24.14503 ] Obstruction of Justice.
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Who will conduct the HMO Government Grievance Procedure for You ? and will You or the designee have 4 years to complete it ? Your Elderly & hospitalized ..... ya think you can live long enough with NO Posthospital Care ???
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Nursing Home Nightmare
Couple Stands Accused of Negligent Homicide in deaths of 34 Elderly Patients ( Sept 14 05 ) but HMO's can deny Covered services causing death with NO Accountability.
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People should be told to Terminate ALL HMO Contracts immediately to stop our Health Care Crisis ....especially in Michigan !!!
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Sincerely,
Kimberly Kimball 10073 Bryce Road Kenokee Twp MI 48006

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