Watchhttp://www.sltrib.com/sltrib/news/54664353-78/care-health-medicaid-acos.html.csp
The story states that there's a potential that the plans will raise the severity of patient diagnoses, and that they're trusting the plans to self-police.
That's not working for nursing homes who bill under the Medicare program for skilled services. All that nursing homes need to do is to stretch the diagnoses... for example; an MD diagnoses a confused patient with "Alzheimer's Dementia" and the nursing home documents that the patient has "Alzheimer's Disease," "Dementia," and "Altered Level of Conciousness." 3 in 1! And all perfectly legal. They can only add diagnoses for which patients are being actively treated - so they document that they are actively treating. A low dose of high blood pressure medicine for a patient who never before had hbp... patients who take multiple meds have the potential for stomach upset so they now have a diagnosis to support the medication.... It happens everyday.
Nursing homes manipulate the system to bill at the highest rates, and the oversight has decreased with the recession. Even when someone reports fraudulent activity, it takes forever to be investigated and a nursing home can appeal the findings. No one will ever know there's a problem, and the nursing homes continue to rake in the bucks.
(shameless plug: Amazon.com "nursing home survival guide - insiders"
My point is that it happens daily in the nursing home industry. Does anyone really believe that it won't happen in the insurance industry? It already is.