09/02/2022    Name Withheld

More Medicare Advantage Fraud

It seems that not a month goes by without another
Medicare "Advantage" Plan found to have their hands
in the CMS cookie jar, having submitted fraudulent
data from your patients charts. The latest carrier
being Wellcare of Florida. A recent OIG study
released today found that of approximately 270
charts they submitted of high risk patients, less
than 1/3 of the charts passed the OIG audit. This
leaves an astonishing failure rate of over 65%.

If your practice submitted 65% of your claims
fraudulently how long would you be able to stay in
practice, escape recoupment and being fit with an
orange jumpsuit? It is clear the Feds are happy to
uncover this fraud, but the elephant in the room is
what is actually being done to the insurance
carriers to punish them? Have any executives of any
MCR "Advantage" plan gone to jail and have any of
these companies paid more than the equivalent of a
parking ticket in fines?

CMS on the one hand wants to flush out fraud
amongst these carriers but seems to have little
desire to put any teeth behind the results of the
studies the OIG conducts, which no doubt cost us,
the taxpayers millions. The ratio of costs of
investigations vs recoupments against healthcare
providers is according to some sources as high or
higher than 1:10. That is for every dollar spent on
investigation, $10 is recouped. Also why not
subject these carriers to penalties more in line
with False Claim Acts, which
can be up to $25K per claim, which at a minimum
would be $4.5M just for this small sample of
charts. Then CMS could, as they do in cases of
provider fraud, extrapolate that into the thousands
of charts submitted and the fines would truly be
appropriate, possibly hundreds of millions of
dollars.

If the OIG and HHS went after MCR "Advantage"
executives the same way they go after healthcare
providers, then we would see high placed
executives' photos in newspapers, perhaps even in
PM News, going to jail with fines in the hundreds
of millions if not billions of dollars being
collected back. Think of what that could do to
promote better healthcare for all. And those would
truly be an impediment to future fraud.

The question is will CMS ever take such action?
The whole idea of "Advantage" plans was for third
parties to take the risk and have the Fed gov't get
out of the insurance business.
Unfortunately as baby boomers become eligible for
MCR and people live longer, the costs of healthcare
are going to go up. The simple fact is more people
are going to need healthcare and more expensive
treatments as the population ages. So the entity
taking the risk now has to figure out a way to
maintain profit. And how is this done?

1) Paying providers less than FFS Medicare,
sometimes at 50% or less than FFS Medicare;
2) Instituting Prior Authorizations and care
denials which are draconian and counter to MCR FFS
policy (this also according to a recent OIG study);
3) And their latest trick, cheating the gov't by
attempting to place patients in a higher risk tier
to collect more revenue.

This is an accountant's dream: Decrease expenses
(Deny care and also pay less to the provider) and
increase revenue collect more from the entity from
your main client, CMS).


Congress is also now looking into complaints from
15 state insurance commissioners lodged by
consumers against Medicare Advantage Plans for
deceptive marketing practices. When is enough,
enough? When will patients and providers alike
realize that the well groomed insurance executives
are common thieves and need to pay the piper for
their crimes? When will providers simply say, we've
had enough of this and
have the gumption to drop out of the plans that
continue to perpetuate criminal activity. It is
time to take a stand!

For more on this story read Wellcare is the latest
MCR Advantage Plan found to be Fraudulent

Name Withheld

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