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Carol S. Miller

First there was Amazon PRIME; now there is another PRIME.

The Act

This Act was introduced into congress in 2013 and contains a number of provisions that would increase rewards and incentives for those who uncover healthcare fraud, as well as heighten penalties for those who commit it.

What it is

The PRIME  Act would enact stronger penalties for Medicare and Medicaid fraud; curb improper or mistaken payments made by Medicare and Medicaid; establish stronger fraud and waste prevention strategies with Medicare and Medicaid to help phase out the practice of “pay and chase” (i.e., recouping monies already erroneously paid to providers instead of detecting problems on the front end); curb the theft of physician identities; expand the fraud identification and reporting work of the Senior Medicare patrol; take steps to help states identify and prevent Medicaid overpayments; and improve the sharing of fraud data across state and federal agencies and programs.





The law directs the Secretary to develop a plan to revise the incentive program under HIPAA for the reporting of fraud and abuse to encourage greater participation by individuals reporting Medicare fraud and abuse.


The law also requires the plan to include certain recommendations for ways to enhance rewards for individuals reporting and an extension of the incentive program to the Medicaid program.


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4 Responses

  1. PP-ACA and the Medicaid Expansion

    Affordable Health Care Act (ACA) was signed by President Obama in 2010 aka Health Care Reform is not a single change but a series of Medicaid Expansion.

    92 different provisions that should emerge over a seven year span. One of the provisions is known as the Providing insurance for the low income communities and individuals who had no health insurance thereby allowing increase in access to health coverage and extending the coverage to sizeable subset of population in need. This will help to create a considerable momentum of healthier people enrolling into Medicare (as they get eligible) who are accustomed to visit doctor’s office rather than going to Emergency Room. Currently Medicaid is covering nearly 70M Americans and has been seen as the main source for financing for safety net hospitals and healthcare carriers who provide services to low income communities.

    With passing of this law critics began to argue that state budgets will be hit hard; due to the fact individuals who were eligible for the programs were unenrolled due to state guidelines but now have to opportunity to re-enroll thanks to the reform. While some critics are against the reform others believe this is a step in the right direction. The Urban Institute has come up with an estimation that state savings will be anywhere between $26B and $52B between 2014 until 2019. Along with the Urban Institute The Lewin Group has also come up with their own speculation that estimates state and local government savings of $101B in uncompensated care.

    While the savings look promising what happens to Medicare and other commercial health insurance companies? In all reality commercial health insurance companies are reaping great benefit from this law. Six months after the law was passed the Los Angeles Times reported the Untied Health group added 75,000 new customers to their insurance programs all stemming from businesses with fewer than 50 employees. Within the first nine months of the new law being passed, a Maryland small business insurer Coventry Health enrolled 115,000 new customers. ACA is creating new member opportunities along with newer market opportunities.

    Medicare is offered to individuals 65+ where are Medicaid can help anyone, the age does not matter. The report “Medicare: Continuous Insurance before Enrollment Associated with Better Health and Lower Program Spending,” found that 18% (nearly 7M) of adults 54-65 did not have health insurance. Majority of these individuals did not have health insurance due to being jobless, working lower-paid jobs that lack employer-based health insurance. These individuals struggle to meet daily expenses. Compared to individuals who have had health insurance prior to Medicare enrollment? The same report shows that these individuals are more likely to report better healthy, costing Medicare on average 35% lower within the first few years of enrollment. The average savings was $2,343 per enrollee.

    While the Medicaid expansion has been proven to save money in Medicare and has provided individuals with the opportunity to achieve better health. There are still issues to be handled as they come across; i.e. administrative issues, costs and enrollment uncertainty, enrollment sustainability/ retention for all programs, provider participation and shortage (especially in rural areas) and the barriers that policy makers will need to face in the upcoming years during these times of change.

    Vicky Parikh MD MPH via Ann Miller RN MHA
    [Executive Director – Population Health]
    Medstar Shah Medical Group


  2. 12 Million People in 2016 Were Enrolled in Both Medicare and Medicaid

    AHIP recently released a report on Medicare-Medicaid dual eligible beneficiaries. Here are some key findings from the report:

    • 12 million people in 2016 were enrolled in both Medicare and Medicaid.
    • 72% of dual eligible individuals receive full benefits.
    • Partial benefit dual eligible individuals comprise 28%.
    • 72% of dual eligible individuals have three or more chronic conditions.

    Source: AHIP, September 2018


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