01/11/2022    Paul Kesselman, DPM

MCR Advantage Compliance Audit

The Office of Inspector General (OIG) just released
"MCR Advantage Compliance Audit of Specific
Diagnosis Codes that Health FIrst Health
Plan Submitted to CMS

I admit, I have not read the entirety of this 52
page document, but the headlines reeks of the
continued fraud I have posted previously committed
by another Part C plan in addition to the many
others previously cited here. These plans are using
our data and then incorrectly reporting that data
to CMS, so they can place patients in a more "at
risk" tier and be paid more money. When CMS then
asks for the charts to support the Part C plans
contention, it is clear the data does not support
the plans contentions. Under similar circumstances,
these same plans would have no trouble recouping
money from you if your charts allegedly did not
support your claims.

That's exactly what's happening here, except now
the Part C plan is the provider being audited and
it certainly doesn't look good for them. Now mind
you we're not talking about a few hundred or
thousands of dollars as may be the case with a
single provider or even a few million dollars with
a hospital system. We are talking about millions
upon millions perhaps hundreds of millions of
dollars collectively for all the Part C Plans
involved in this type of behavior. And despite this
continued fraud, CMS wants more patients to enroll
in MCR Advantage Plans.

Upon what basis does CMS have it that fraud and
costs will be better contained with Part C plans,
if they don't criminalize these acts and have the
executives at MCR Part C Plans subject to civil and
criminal penalties, similar to what you and I would
face if we were to commit similar actions?

If CMS continues allowing Part C plans to data mine
our data and falsely represent it, they are
perpetuating the fraud that every taxpayer and
health care provider needs to be outraged about.

The message which CMS likely does not have the
backbone to support is simple and the same facing
any health care provider committing fraud:
You commit data mining fraud and those signing the
reports face heavy civil penalties and real jail
time. Second, your company is banned from Medicare
contracts for five years. Third and last CMS now
has the right to look at all your books for the
past seven years and recoup money from you that was
incorrectly paid by CMS to you to run a Medicare
Advantage Plan.

How many MCR C plans do you think will be left
standing?

However, these same carriers are playing hardball
with you and committing fraud themselves.

Paul Kesselman, DPM, Oceanside, NY

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