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Medicare Chief Orders Probe of Florida HMOs

November 4, 1990

ST. PETERSBURG, Fla. (AP) _ The overseer of the nation’s Medicare program ordered an investigation of Florida health maintenance organizations with federal contracts to scrutinize marketing and patient practices.

Richard Kusserow, inspector general for the Health and Human Services Department, will conduct the investigation, which was prompted by media reports of abuses and inquiries from two Florida congressman.

Much of the attention will focus on Humana Gold Plus, by far the state’s largest HMO for Medicare beneficiaries.

The Gold Plus plan, which has about 200,000 clients, has been the subject of 5,440 complaints since June 1987, ranging from improper enrollments to failure to provide service.

The Gold Plus plan was cited twice last year by the Health Care Financing Administration, Medicare’s parent agency, for violating medicare regulations, including improperly denying claims, enrollment problems and excessive payment delays.

Gail R. Wilensky, chief of the Health Care Financing Administration, said Friday she picked Kusserow to investigate. Medicare placed a moratorium on Humana’s plans to expand into other parts of Florida pending the outcome of the investigation.

Other complaints against Gold Plus involved bills the plan did not pay or decisions that left patients harassed by bill collectors.

The government pays Humana a fixed fee monthly for each enrollee. Patients are to receive complete health care services and prescription drugs at little or no cost and aren’t supposed to have to fill out insurance forms.

Wilensky said she decided to launch the investigation after she was contacted by Florida Congressman E. Clay Shaw Jr. and Larry Smith and learning of media reports about patients complaints about Gold Plus.

Shaw and Smith wanted to ensure HMOs were following federal regulations, she said.

Humana spokesman Tom Noland dismissed the investigation as politically motivated. He said he couldn’t respond to Medicare’s concerns because the organization has not received anything in writing.

″If they ask us to do something, how can we do it if we don’t know what it is?″ he said.

The HMOs could lose their federal contracts to provide for Medicare patients if the investigation uncovers wrongdoing. Other punitive action could be brought by Congress.

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