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Christine White pays $300 a year more for her health care because she refused to join her former employer’s wellness program, which would have required that she fill out a health questionnaire and join activities like Weight Watchers.

“If I didn’t have the money … I’d have to” participate, says White, 63, a retired groundskeeper from a Portland, Ore., community college.

Like many Americans, White gets her health coverage through an employer that uses financial rewards and penalties to get workers to sign up for wellness programs. A small but growing number tie those financial incentives to losing weight, exercising or lowering cholesterol or blood-sugar levels. The incentives, meanwhile, can add up to hundreds, or even thousands, of dollars a year.

Employers say wellness programs boost workers’ health and productivity while helping companies curb rising health care costs. President Obama’s signature health law allows employers to increase those financial incentives. But asking workers to undergo medical exams or give personal medical information is sharply limited by another law, the 1990 Americans With Disabilities Act, which prohibits such questioning — except under limited circumstances, such as by voluntary wellness programs.

So when is a wellness program voluntary, and when do employer incentives cross the line and become coercive?

A proposed rule published this spring by the Equal Employment Opportunity Commission attempts to strike a balance between employers who want to use incentives to drive worker participation and consumer advocates who see penalties as de facto coercion. The plan drew about 300 comments from employers and consumer groups by a June 19 deadline, with plenty of criticism.

The equation tilts too far against workers, said Samuel Bagenstos, a University of Michigan Law School professor. “When … employers can charge you a couple thousand dollars more for refusing to give private medical information, [that] doesn’t sound very voluntary to me.”

Many employers say the proposed rule doesn’t clear up the conflicts between the health law and the ADA. In addition, it restricts their ability to offer rewards, which are needed to “engage employees and their families to be aware of their … lifestyle risks,” said Steve Wojcik, vice president of public policy for the National Business Group on Health.

The EEOC hasn’t set a timetable for issuing a final rule.

Under the proposal, wellness programs would be considered voluntary so long as the employer rewards or penalizes an employee no more than 30 percent of the cost of health insurance for a single worker. Since the average cost for such coverage is $6,025 a year, the 30 percent limit would be about $1,800.

Employers can’t fire workers for declining to participate, nor can they deny them coverage, the proposal says. They also must give workers a notice explaining what medical information will be obtained by the wellness administrator — often a private contractor — and how that might be used.

Some employers say the rule could force them to cut the size of wellness programs’ financial incentives or penalties, particularly for families and smokers. Such limits could mean “advancements in workplace health improvement may come to an end,” wrote the Northeast Business Group on Health, a coalition of large employers, insurers and benefit consultants.

Consumer groups are also unhappy, saying the proposal strips workers of important protections against health or disability-related discrimination by loosening earlier government definitions of what constitutes a voluntary program.

“It walks back people’s rights,” said Jennifer Mathis, director of programs for the nonprofit Bazelon Center for Mental Health Law, a legal advocacy organization for people with mental disabilities.

The health law permits employers to offer incentives or penalties of up to 30 percent of the cost of a health insurance plan — up from 20 percent under a previous regulation — if they set specific health goals for workers, such as quitting smoking or achieving certain results on medical tests. Most employers’ incentives are still well below those levels.

Still, how does that square with the ADA’s restrictions on employers asking for personal medical information? That’s where it gets complicated. The EEOC long defined voluntary wellness programs under the ADA as those where “an employer neither requires participation, nor penalizes employees who do not participate.”

But what constitutes a penalty? Prior to the proposed rule, employers who tried to charge workers the full cost of their insurance, or who barred them from coverage for refusing to participate, could run into trouble, said Sarah Millar, a partner at law firm Drinker Biddle in Chicago.

“What was not clear was at what point between zero and 100 percent [of the cost of employee health coverage], does a program not become voluntary?” she said. “Now, as long as it’s below 30 percent and meets certain disclosure requirements, then a program is still considered voluntary.”

Many employers also asked the administration to allow them to impose penalties of up to 50 percent of insurance costs for tobacco users, which the federal health law allows.

Additionally, employers want to be able to charge workers 30 percent of the cost of more expensive family coverage, if the family is also eligible to participate in the wellness program. That could dramatically increase the dollar amount of the financial incentive or penalty.

But some consumer advocates say the proposed level of financial incentives or penalties is already too punitive.

“Medical questions that an employee may only decline to answer if he or she agrees to pay thousands of dollars more for health insurance can hardly be called ‘voluntary’,” the Bazelon center wrote. The group wants the government to prohibit penalties for those who decline to answer such questions.

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For its first 25 years, the U.S. Preventive Services Task Force toiled in relative obscurity.

Created by the federal government in 1984, the task force published books and articles in scientific journals that aimed to inform primary care practitioners about which preventive services were effective based on scientific evidence. It assigns preventive services such as screenings, medication and counseling grades from A to D, or an I for insufficient evidence.

In 2010, everything changed.

The massive health care bill that came to be called Obamacare included language requiring that preventive services scoring a grade of A or B from the task force had to be covered by health plans without charging consumers anything out of pocket. In one stroke, this volunteer group of nonpartisan medical experts found themselves thrust into the political hurly-burly. Their recommendations, including a controversial 2009 recommendation regarding breast cancer screening, came under intense scrutiny.

Dr. Michael LeFevre, a primary care physician who is vice chairman of the Department of Family and Community Medicine at the University of Missouri, chaired the task force for 10 years. He stepped down from that position in March. We spoke recently about his tenure and how the task force’s role has evolved. The following interview has been edited and condensed.

How did the health law change the role that task force recommendations play in health care?

It would be disingenuous of me not to suggest that the link between the task force A and B recommendations and insurance coverage hasn’t put an additional focus on our work. There are people who think we are making a coverage decision. We’re not. We evaluate the science; we don’t look at the costs. If the science doesn’t make clear there’s at least moderate certainty of net benefit, we don’t recommend it. We know if we give it an A or a B, there will be a link to coverage, but we’re not saying it should be covered.

Let’s talk about the breast cancer screening recommendation. The task force in 2009 and again several months ago in a proposed update did not recommend mammograms for women age 40 to 49. The task force gave it a C rating, which means they should be offered selectively depending on patient preferences and health history in consultation with a physician. Some say this is a big mistake, that women in that age group won’t get mammograms that may help detect breast cancer earlier. How do you respond to critics?

In 2009, when we released our recommendation for breast cancer screening, we were in the middle of the debate in Congress about the Affordable Care Act. And it was already written into the bill being considered that A and B recommendations would be covered without a copayment. So we became the focus of debate about the recommendation and coverage. This created a firestorm of publicity that was, honestly, ultimately good.

We were already working to try to improve our transparency and communication. I’d be dishonest to say that it didn’t influence us. We realized that we have to be faster and clearer. Our audience is beyond primary care physicians, there are payers, government bodies and patients to consider.

But what about the charges of critics such as Rep. Debbie Wasserman Schultz, D-Fla., a breast cancer survivor, who wrote in The Washington Post, “We know that mammograms are not perfect, but we also know that deferring them until after age 50 is dangerous.”

It’s important for us to separate out the issue of coverage from the science itself and the benefits and harms. We are well aware that many payers cover not only C recommendations but also D recommendations. All the ACA really does is set a floor and says that A and B recommendations have to be covered.

How do you decide which preventive services to review?

We try to update existing topics every five years, more or less often depending on events. Occasionally we retire a topic.

Anybody can nominate a new topic at any time. We have a work group that looks at it continuously. We have to decide, is it prevention, and is it something that can be implemented or referred by primary care clinicians? For example, we saw that Vitamin D deficiency screening was being promoted widely. We decided it was an important topic to review.

What other task force recommendations have been publicly controversial?

The 2009 breast cancer screening recommendation was the peak of public scrutiny. But the breast cancer screening recommendation for women 40 to 49 is not negative [since it suggests that mammography can be offered based on the views of the doctor and patient]. In contrast, we recommended against prostate cancer screening. We gave it a D. To my knowledge nobody has stopped covering prostate cancer screening. We got a lot of attention for that. We still get a lot of attention and some advocates still want that to change. I am surprised about the depth of feeling about the recommendations.

In your role as the immediate past chairman of the task force, you’re involved as a consultant until next spring. What’s on the drawing board going forward? How will the task force change and evolve in the next 10 years?

I look for us to continue to try to be transparent in our work. I can’t tell you exactly what shape that will take as we go forward. We’re not the wizard behind the curtain that makes decrees. We want people engaged in our work and to know how we do that work. Did we miss something, did we reach the right conclusions?

I look for us to increase communications. We are increasingly putting out tools for consumers on the Web. I’m probably not supposed to tell you this, but what the heck. Part of our method now, after we’ve reviewed the evidence, we actually have somebody from the communications team get up and grill us. A non-clinician. We feel like if we can’t explain it, we haven’t done our job. We appreciate that our language has to go beyond what a clinician understands.

Transparency, methodological rigor and communications. That’s what we’re focusing on.

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Fraud and abuse continue to dog Medicare’s popular prescription drug program, despite a bevy of initiatives launched to prevent them, according to two new reports by the inspector general of Health and Human Services.

Their release follows the arrests of 44 pharmacy owners, doctors and others, who last week were accused of bilking the program, known as Part D.

The two reports issued Tuesday provide more insight into the extent of the fraud, as well as steps federal regulators should take to stop it. The first report, which covers data from last year, found:

• More than 1,400 pharmacies had questionable billing practices last year in the drug program. Some billed for extremely high numbers of prescriptions per patient and others billed for a high proportion of narcotic controlled substances. Collectively, they billed Part D $2.3 billion in 2014.
• Prescriptions for commonly abused opioids continue to rise, despite warnings about inappropriate use. Between 2006 and 2014, Medicare’s spending on them grew to $3.9 billion from $1.5 billion, a 156 percent increase. By comparison, spending for all drugs in the program, including expensive specialty medications, grew by 136 percent during the same period. More than 40 percent of Medicare beneficiaries in Alabama, Tennessee, Oklahoma and Alaska filled at least one prescription for a narcotic in 2014, compared to 32 percent for the nation as a whole.
• New York and Los Angeles remain hot spots for questionable prescribing, with far higher use of expensive drugs associated with fraud than other parts of the country. The New York metropolitan area, for instance, accounted for half of all prescriptions for the expensive topical ointment Solaraze last year, a disproportional rate. The drug is used for lesions formed as a result of overexposure to the sun. New York and Los Angeles also stood out for prescribing of two omega-3 fatty acids, used to help reduce very high triglyceride levels. The two regions accounted for nearly half of all prescriptions for Vascepa and about a third of those for Lovaza.

The inspector general’s findings come two years after ProPublica reported on how weak oversight by the Centers for Medicare and Medicaid Services (CMS) allowed abusive prescribing and outright fraud to proliferate in Part D. Medicare promised a more aggressive approach to analyzing its own data.

People can use Prescriber Checkup, a tool created by ProPublica, to look up doctors and see how their prescribing patterns compare to peers in the same specialty and state.

Medicare Part D provides drug coverage for 39 million seniors and disabled people, at a cost of $121 billion in 2014. It is the fastest-growing component of the Medicare program. Part D is administered by health insurers under contract with the federal government, but CMS is responsible for overseeing it.

For years, the inspector general, an internal watchdog that evaluates HHS programs and investigates wrongdoing, has dinged Medicare for its failure to keep a close enough eye on doctors, pharmacies, beneficiaries and even its fraud contractors. That’s beginning to change, officials say.

“CMS has made progress on a number of recommendations we’ve made, as well as on the initiatives that they’ve had,” said Jodi Nudelman, regional inspector general for evaluation and inspections in the New York office. “They’re starting to use data to drive their strategies.”

At the same time, she said, “There are still concerns. More needs to be done. We can’t stop here.”

A second report from the inspector general says that Medicare needs to adopt a number of reforms that it has so far resisted. They include:

• Requiring health plans to report all potential fraud and abuse to CMS and its fraud monitoring contractors. Right now, the agency encourages plans to voluntarily report suspicions of fraud but it doesn’t mandate it. Last year, the inspector general found that less than half of Part D insurers voluntarily reported data on potential fraud and abuse.
• Expanding reviews for questionable drug prescribing beyond controlled substances to other commonly abused drugs, including antipsychotic medications, respiratory drugs and those for HIV.
• Restricting patients suspected of doctor shopping—visiting multiple doctors in search of controlled substance prescriptions—to a limited number of doctors and pharmacies. CMS said it doesn’t have legal authority to do this, but the inspector general said it should seek the authority, which is commonly used by private insurance companies and state Medicaid programs for the poor.

During last week’s Medicare fraud takedown, 243 people total were arrested, including 46 doctors, nurses and other licensed health professionals. Forty-four of the people arrested were charged with fraud related to Part D.

In Miami, for example, a number of pharmacy owners were charged with health care fraud and conspiracy to commit fraud. In one case, the government charged several people with paying Medicare beneficiaries for their personal identification numbers, which they used to file fraudulent claims for drugs that were never dispensed. They worked with a clinic owner, who forged and altered prescriptions and sold them to the pharmacies. This scheme alone defrauded Medicare of $21.2 million, the government alleges.

Last year, CMS announced that it was granting itself potent new authority to expel physicians from Medicare if they are found to prescribe drugs in abusive ways. The agency also said it would compel health providers to enroll in Medicare to order medications for patients covered by Part D. Currently, that isn’t required.

The changes were supposed to take effect on June 1, but have since been delayed twice, most recently until January 1.

CMS spokesman Aaron Albright said Monday in a written statement that Medicare “works diligently with our law enforcement partners to prevent fraud in the first place and to recover payments for wasteful, abusive or fraudulent services.”

In addition to requiring 400,000 prescribers to enroll in Medicare by next year to order to retain the ability to prescribe in Part D, Albright said, officials are helping health plans decrease overuse of dangerous drugs and taking action against providers and pharmacies with potentially fraudulent billing practices.

In April, CMS launched a web-based tool to allow CMS, law enforcemen, and health plans to share information and coordinate actions against pharmacies deemed high risk. CMS also said it is monitoring potentially fraudulent activity in geographic hot spots like the ones identified by the inspector general.

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Terri Anderson signed up for California’s Medicaid program earlier this year, hoping she’d finally get treatment for her high blood pressure. But the insurer operating her Medicaid plan assigned the 57-year-old to a doctor across town from her Riverside, Calif., home and she couldn’t get there.

“It was just too far away,” says Anderson, adding that she cares for her 90-year-old ill father and can’t leave him alone to make an hour round-trip drive to the doctor. Now she’s crossing her fingers that a health clinic near her house will accept her new insurance.

She’s not alone. In an effort to control costs in its rapidly expanding Medi-Cal program, California has relied heavily on managed care insurance companies to treat patients like Anderson.

The state pays insurers a fixed amount per enrollee and expects the companies to provide access to doctors and comprehensive care. But a scathing state audit released last Tuesday shows that California is failing to make sure those plans deliver. Many enrollees have insurance cards but often have trouble getting in to see a doctor.

The state didn’t verify that insurers’ directories of doctors were accurate, the audit found, or that the plans had enough doctors to meet patients’ needs. The state Department of Health Care Services also didn’t do its own required annual audits of the plans.

And thousands of phone calls to an ombudsman’s office — created to investigate complaints — went unanswered every month.

The audit focused on three health plans, but underscores a broader problem in California: the lack of sufficient oversight of a program that now serves about 12 million beneficiaries, three quarters of whom are in managed care. Advocates and analysts say the state has moved too quickly to shift enrollees into managed care plans and given too much unsupervised responsibility to the companies.

While people enrolled in the old, fee-for-service Medicaid system sometimes had difficulty finding doctors, especially specialists, the difference is the managed care plans have a legal responsibility to provide sufficient access to their consumers.

The sheer number of enrollees, along with the complexity of their health care needs, means the state needs to do a better job tracking the plans responsible for caring for them, said Gerald Kominski, director of the UCLA Center for Health Policy Research.

“The audit indicates now that so many Californians are enrolled, how important it is for the state to have adequate oversight,” Kominski says. “The state has a long way to go to reach that goal.”

Aimee Mejia, a single mother in South Gate, just a few miles southeast of downtown Los Angeles, said finding specialists to treat her diabetes and psoriasis was challenging. Some didn’t accept her Medi-Cal insurance and others were too busy to see new patients. She finally found doctors, but driving to one takes about 40 minutes and the other, more than an hour.

“I thought that was normal, to be rejected by doctors or to wait for care,” Mejia says. “But there is something wrong here.”

New proposed federal regulations designed to improve Medicaid managed care could help by requiring states to ensure that patients have enough access to doctors and hospitals. The regulations also would limit profit margins and establish a quality rating system for plans. In addition, a proposed bill in California would require plans to provide accurate and up-to-date provider directories.

Officials at the state’s Department of Health Care Services say they already have made some changes and are monitoring doctor networks more thoroughly than the audit found.

But even if oversight improves, many argue that the only way to get more doctors and other providers to participate in Medi-Cal is to increase payments. A coalition of unions, doctors and hospitals are pushing to raise rates in California. If that doesn’t happen, more regulation will only go so far, says Sean Wherley, spokesman for SEIU-United Healthcare Workers West.

“If there still aren’t doctors taking new Medi-Cal patients, how is that any better for patients?” he said.

The issue of managed care oversight isn’t limited to California. Several states have transferred responsibility to managed care insurers but aren’t closely tracking whether Medicaid patients are getting the care they need, says Joan Alker, executive director of the Georgetown University Center for Children and Families.

“This is a national problem,” Alker says. “More beneficiaries with chronic and difficult health conditions and more public dollars are going into managed care. We absolutely need more accountability.”

Oversight has been hurt by state budget cutbacks and the loss of seasoned employees, Alker says. In addition, for-profit companies running managed care plans have a responsibility to return profits to their shareholders. “That comes up against the responsibility of dealing with a population of people who have a lot of health care needs,” Alker said.

California has been moving large numbers of poor patients into managed care for decades. Over the past few years, however, the pace has accelerated. Many newer beneficiaries, including seniors and people with disabilities, have multiple chronic illnesses. And people who gained Medi-Cal coverage through the Affordable Care Act also may have gone without treatment for a long time and have serious health needs.

Each transition has been rocky, with patients and advocates raising concerns about patients’ inability to find primary care doctors or specialists.

Linda Lindsey, 60, lives in Weaverville, a rural town outside Eureka in far northern California that has a limited number of doctors. Lindsey says she was moved into a Medi-Cal managed care plan a few years ago, and has even fewer options for doctors and pharmacies than she did before.

At one point, Lindsey, who has Crohn’s disease, said she drove about 50 miles to see a specialist only to be told that the office didn’t accept her plan. “I was upset, to say the least,” she said.

Some of the issues have arisen because Medi-Cal grew much faster and bigger than anybody predicted, says Stan Rosenstein, a consultant and former chief deputy director at the state health care services department. The numbers jumped from 6.6 million enrollees in 2007 to 12.2 million to this year.

But caring for people through managed care is a vast improvement over the old fee-for-service system, Rosenstein says. In that, doctors got paid per visit. In managed care, he says, “There is a lot more measurement, a lot more accountability and a lot more contractual requirements than there ever had been.”

There are numerous laws on the books requiring state monitoring and sufficient access to doctors. For example, California is required to determine that plans have enough doctors and that patients don’t have to travel too far to reach them. State officials also must do regular assessments of plans to determine whether they can meet their contractual obligations.

But just having laws isn’t enough to ensure that patients’ needs are met, says Abbi Coursolle, a staff attorney at the National Health Law Program. “Those standards are only as good as the state’s ability to enforce them,” she said.

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Congress’ official scorekeeper says repealing Obamacare would increase the federal budget deficit and the number of uninsured Americans by 24 million.

The report from the Congressional Budget Office comes as Washington awaits a ruling by the Supreme Court that could end insurance subsidies for some six million people in 30 states.

The report says repealing the Affordable Care Act’s spending cuts and tax increases would add $137 billion to the deficit over the next ten years, and the number of people with health insurance would drop from 90 percent of the population to 82 percent.

The CBO says economic growth would be boosted a bit because more people would join the labor force, as the Affordable Care Act’s subsidies make it easier for people to work less or stop working and not lose health coverage.

Reaction to the report, as with most things about the health care law, fell along party lines. The chairman of the Senate Budget Committee, Republican Mike Enzi of Wyoming, chose to focus on how repeal would effect economic growth:

“‘CBO has determined what many in Congress have known all along,’ said Chairman Enzi. ‘This law acts as an anchor on our economy by dragging down employment and reducing labor force participation. As a result, the deficit reduction that the Democrats promised when it was enacted is substantially unclear.'”

Democrats put their focus on the negative impacts of repeal. House Minority leader Nancy Pelosi said:

“The cost to the deficit would be surpassed only by the human toll of repeal. Republicans would add over 20 million Americans to the ranks of the uninsured, and strip vital health protections from hundreds of millions of American families – shattering the newfound health security that has made a difference in the lives of so many families. Republicans should look at the numbers and finally end their fixation with repealing this historic law.”

The new CBO report incorporates the principles of dynamic scoring, which takes into account a wider array of economic factors, and which Republicans say provides a more realistic picture of the economic impact of repeal. The CBO says under the old rules, the deficit would increase even more, by $353 billion over ten years.

Politico says the CBO report could have political implications:

“The estimate will make it harder for Republicans to use so-called reconciliation to repeal the law because congressional budgeting rules bar lawmakers from using the parliamentary maneuver to move legislation that adds to government red ink.

The CBO report said over the long term, repeal would add even more to the deficit:

“Repealing the ACA would cause federal budget deficits to increase by growing amounts after 2025, whether or not the budgetary effects of macroeconomic feedback are included. That would occur because the net savings attributable to a repeal of the law’s insurance coverage provisions would grow more slowly than would the estimated costs of repealing the ACA’s other provisions—in particular, those provisions that reduce updates to Medicare’s payments. The estimated effects on deficits of repealing the ACA are so large in the decade after 2025 as to make it unlikely that a repeal would reduce deficits during that period, even after considering the great uncertainties involved.”

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Federal agents have arrested 243 people — including 46 doctors, nurses and other medical professionals — who are accused of running up more than $700 million in false Medicare billings. Charges range from fraud and money laundering to aggravated identity theft and kickbacks.

Attorney General Loretta Lynch calls it “the largest criminal health care fraud takedown in the history of the Department of Justice.”

One California doctor is accused of causing nearly $23 million in fraud losses, due to illegal practices that involved “over 1,000 expensive power wheelchairs and home health services that were not medically necessary and often not provided.”

The arrests took place over three days in 17 cities. The FBI says more than 44 of the defendants defrauded Medicare’s Part D prescription drug program.

Others are charged with running schemes based on overstating treatment times — and in one case, the defendants are accused of billing Medicare millions of dollars for equipment that were either not needed or requested.

More than 900 law enforcement officials were involved in the arrests, which the Justice Department says are the latest in a crackdown on Medicare fraud.

Since it was formed in 2007, the Medicare Fraud Strike has “charged over 2,300 defendants who collectively have falsely billed the Medicare program for over $7 billion,” the government says. It adds that in that same span, the strike force has prosecuted more than 200 doctors and more than 400 medical professionals.

Last summer, our colleagues at the Shots blog reported on a separate prescription drug scheme that unraveled after a doctor’s Part D billing soared to nearly $5 million. In that case, two secretaries at the doctor’s clinic were found to have faked prescriptions.

Announcing this week’s arrests, officials said, “the Centers for Medicare & Medicaid Services also suspended a number of providers.”

From the FBI’s news release, here are more of the charges:

Miami: 73 defendants were charged with offenses relating to their participation in various fraud schemes involving approximately $263 million in false billings for home health care, mental health services and pharmacy fraud. In one case, administrators in a mental health center billed close to $64 million between 2006 and 2012 for purported intensive mental health treatment to beneficiaries and allegedly paid kickbacks to patient recruiters and assisted living facility owners throughout the Southern District of Florida. Medicare paid approximately half of the claimed amount.

Houston and McAllen, Texas: 22 individuals were charged in cases involving over $38 million in alleged fraud. One of these defendants allegedly coached beneficiaries on what to tell doctors to make them appear eligible for Medicare services and treatments and then received payment for those who qualified. The company that paid the defendant for patients submitted close to $16 million in claims to Medicare, over $4 million of which was paid.

Dallas: Seven people were charged in connection with home health care schemes. In one scheme, six owners and operators of a physician house call company submitted nearly $43 million in billings under the name of a single doctor, regardless of who actually provided the service. The company also significantly exaggerated the length of physician visits, often times billing for 90 minutes or more for an appointment that lasted only 15 or 20 minutes.

Los Angeles: Eight defendants were charged for their roles in schemes to defraud Medicare of approximately $66 million. In one case, a doctor is charged with causing almost $23 million in losses to Medicare through his own fraudulent billing and referrals for DME, including over 1000 expensive power wheelchairs and home health services that were not medically necessary and often not provided.

Detroit: 16 defendants face charges for their alleged roles in fraud, kickback and money laundering schemes involving approximately $122 million in false claims for services that were medically unnecessary or never rendered, including home health care, physician visits, and psychotherapy, as well as pharmaceuticals that were billed but not dispensed. Among these are three owners of a hospice service who allegedly paid kickbacks for referrals made by two doctors who defrauded Medicare Part D by issuing medically unnecessary prescriptions.

Tampa: Five individuals were charged with participating in a variety of schemes, ranging from fraudulent physical therapy billings to a scheme involving millions in physician services and tests that never occurred. In one case, a licensed pain management physician sought reimbursement for nerve conduction studies and other services that he allegedly never performed. Medicare paid the defendant over $1 million for these purported services.

Brooklyn, N.Y.: Nine individuals were charged in two separate criminal schemes involving physical and occupational therapy. In one case, three individuals face charges for their roles in a previously charged $50 million physical therapy scheme. In the second case, six defendants were charged for their roles in a $8 million physical and occupational therapy scheme.

New Orleans: 11 people were charged in connection with $110 million in home health care and psychotherapy schemes. In one case, four individuals who operated two companies—one in Louisiana and one in California—that mass-marketed talking glucose monitors (TGMs) across the country allegedly sent TGMs to Medicare beneficiaries regardless of whether they were needed or requested. The companies billed Medicare approximately $38 million for the devices and Medicare paid the companies over $22 million.

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Marlene Allen thought she had decent medical coverage after she fell in December and broke her wrist. She had come in from walking the dogs. It was wet. The fracture needed surgery and screws and a plate.

Weeks later, she learned her job-based health plan would cover nothing. Not the initial doctor visit, not the outpatient surgery, not the anesthesiology. She had $19,000 in bills.

“Make sure you find out what kind of plan it is” when employers offer coverage, advises Allen, who lives in northern Minnesota. “I thought health insurance was health insurance.”

A complex health law and bad information helped cause the trouble.

When her employer offered the health plan late last summer, Allen thought she had to sign up. That was wrong.

Once she was on the employer plan, she thought she had to drop the better, more comprehensive coverage she had bought through MNsure, the state’s online insurance marketplace. That was also wrong.

After she learned that her work plan covered hardly anything, and she tried to get back on a marketplace policy, MNsure told her she’s not eligible for subsidies to buy it. Wrong again.

“Horrible situation,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms. It “does make you wonder about the training these call-center folks are getting.”

Last September, with an impending January deadline for employers to provide some sort of health insurance, in accordance with the federal health law, Allen’s employer introduced a plan that covered only vaccines, blood-pressure tests and other preventive care.

Skimpy though they are, such benefits meet one of the law’s tests — the one that says employers must offer “minimum essential coverage” or pay a fine of about $2,000 per worker. (The skimpy benefits do not, by the way, pass a second requirement — that employer coverage offer “minimum value,” including hospitalization. Flunking that test can result in a different fine of up to $3,000 per worker.)

Allen works for Independence Plus, a home-care agency. She takes care of her disabled son, who has multiple sclerosis, and gets paid through a state program as the company’s employee.

Last fall, she joined the agency’s minimum essential coverage plan and dropped her comprehensive MNsure plan. She knew the new coverage wasn’t great, but she thought it would at least cover surgery. She believed she was obligated to take the coverage, and didn’t notice that the insurance card says, “Preventive Services Only.”

She was shocked when she learned it covered none of the charges for her broken wrist. She had always been careful to have medical insurance. Suddenly she faced hospital bills equal to more than half her annual income.

“I don’t even want to call it a health plan,” she says. “It should be illegal.”

Minimum essential coverage policies, also known as “skinny plans,” spread last year as lower-wage employers — such as temp agencies and hotels — adopted them as a shield against the $2,000 federal fine. Unlike Independence Plus, many employers supplement skinny plans with other health insurance, although even some of those lacked hospitalization benefits until federal regulators moved to ban them.

“There aren’t too many companies that are doing just [these skinny] plans,” said George Reardon, a Houston benefits lawyer who works with staffing companies.

Ruby Baranski, who heads Independence Plus, says her firm can’t afford more comprehensive benefits or even get insurers to offer them because of high worker-turnover. She blames President Barack Obama and the Affordable Care Act for forcing her to offer a minimal plan to avoid the fine of $2,000 per employee.

“I kind of got slapped with this,” Baranski says.

Faced with no way to pay her huge bill, Allen applied for assistance from the health system that fixed her arm. Sanford Health would not comment on her case, but on June 3, it sent Allen a letter agreeing to wipe out its entire, $17,200 bill. That would leave her with only a $1,800 charge from the anesthesiologist.

Allen is grateful. But she’s also worried, because the skinny, preventive-only plan is still her only health insurance. In February she told a representative of MNsure that she wanted to get back on a marketplace plan.

Allen explained to MNsure that her workplace plan doesn’t cover hospitalization. She asked whether she could get subsidies to buy a comprehensive MNsure plan — the only way, with her $37,000 annual income, that she could afford the comprehensive policy’s monthly premiums.

No, MNsure said. Because Allen was offered an affordable plan at work, MNsure said, she could not get tax credits to help subsidize the premiums she’d pay for a marketplace plan.

That’s the wrong answer. All consumers in Allen’s income range do qualify for subsidies unless an employer plan is both affordable and meets the minimum value test with hospital, doctor and drug benefits. (There’s one more special case: Consumers eligible for a government program like Medicare are ineligible for subsidies aimed at defraying the cost of marketplace plans.)

Independence Plus’s plan is affordable, but because of its skimpy, preventive-only benefits it falls far short of “minimum value” under the law.

Once Allen learned she had gotten bad information, MNsure’s regular enrollment period for 2015 was over; it was too late to sign up. She applied for an exception so she wouldn’t have to wait until next year to get covered.

MNsure spokesman Joseph Campbell acknowledges the error, but says it was a rare exception. The marketplace’s employee training manual addresses both affordability and minimum value, he says.

But on Wednesday Allen got a letter stating again that she is ineligible for tax credits because she has access to insurance elsewhere.

“Boy, something is so wrong with this,” she says.

The bigger lesson, Allen says, is this: Don’t assume insurance offered by your employer is real medical coverage.

“You think when the word ‘insurance’ is said, it should cover you for everything,” Allen says. Now she knows that’s not true.

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Just over half of all pregnancies in America are unplanned.

The most effective reversible birth control methods are hormonal implants and intrauterine devices. Less than 1 percent of women using these long-acting contraceptive methods will become pregnant over the course of a year. That’s compared to 9 percent of women using the pill who will get pregnant, and to 18 percent of women whose partners use a condom.

Yet fewer than 12 percent of women who report using birth control have an IUD or hormonal implant.

Researchers from the University of California, San Francisco had an interesting idea about how to increase that rate. Instead of directly educating women about IUDs and implants, they conducted a study to see if educating health care workers about the latest innovations and statistics regarding contraceptives would make a difference.

It did. Unintended pregnancy rates among young women in the study dropped by almost half.

“Providers were much more likely to counsel them on these highly effective methods — IUDs and implants,” says Cynthia Harper, the UCSF professor and family planning researcher who led the study. “Women had demonstrated greater knowledge of these methods. They were more likely to select them.” Details of the findings were published Tuesday in the Lancet.

Harper says a number of new contraceptive methods have come out in the last few years, including the hormonal IUD and the contraceptive implant. The training administered in the study helped clinicians understand technicalities of each method, including their benefits, side effects, and which method might be most appropriate for patients with various needs.

UCSF partnered with 40 Planned Parenthood clinics across 15 states in the study. Workers at half the clinics received the latest training about birth control methods; half did not.

The discussion of IUDs and implants was starkly different in clinics where counselors got the extra training compared to clinics without the training: 71 percent of providers who received training brought up these long-term birth control methods with their patients, versus 39 percent of providers in the control group.

Fifteen-hundred women, ages 18 to 25, were enrolled in the study. They were eligible only if they said they wanted birth control counseling and that they did not want to become pregnant. Those who received counseling from health care workers who had undergone the recent update training on contraceptive methods chose an IUD or implant 28 percent of the time. Only 17 percent of women at the control clinics chose those methods.

Harper says a major barrier for many women in choosing an IUD or implant was cost. IUDs can cost up to $1,000. But they actually are more cost-effective than other methods over time, since their effectiveness lasts for years.

The study was done from 2011-2013, before the Affordable Care Act — and its coverage of birth control — took full effect, and 38 percent of the women studied did not have health insurance.

“I’m hopeful that if the ACA is in place and if women are more likely to be insured for contraceptives, then they’ll be able to afford these methods that have higher upfront costs,” Harper says.

The pregnancy rate dropped from 15 percent to 8 percent over the course of the study. But for reasons the researchers say they can’t explain, that drop only occurred among women who came to the clinic specifically seeking contraception and family planning counseling. There was no change in the pregnancy rate among women who sought birth control after an abortion.

The researchers found that fewer women who wanted to use an IUD or implant after an abortion were actually able to get them. Nearly a quarter of these women were pregnant again within a year.

Only 44 percent of the women who chose IUDs or implants after an abortion actually obtained them, Harper says.

“Now we’re looking at why,” she says. “What were the restrictions?” Harper notes that there are restrictions in the use of public money for birth control in clinics that provide abortions.

This story was produced by State of Health, KQED’s health blog.

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