10/07/2022    Name Withheld

MCR Advantage Plan Again Found with its Hand in the "Cookie Jar"

A recently reported OIG study found that the
Highmark Medicare Advantage plan was the latest
in a slew of previously reported MCR Advantage
plans to provide unsubstantiated data to CMS.
This data (was then used to obtain higher payments
than they were supposed to receive ($800K) from
CMS for managing their MCR Advantage Plans for the
time specified in the report. What is the source
of the data which is fraudulently manipulated? Its
source is from providers and the charts we elect
to provide to the carrier, which the carriers then
change and submit to CMS.

There have been relatively few complaints posted
in many podiatric and other medical forums in
comparison to the barrage of requests from MCR
Advantage plans. However, when I speak with most
doctors (MD/DO/DPM) they all acknowledge they have
complied with these endless requests, most often
without payment.

So here is my question to the OIG, CMS and anyone
else who is monitoring this forum:
If a practitioner would submit fraudulent data, we
see endless reports in the OIG about doctors
wearing orange jumpsuits and how much money they
"stole" and how this threatens the MCR Trust fund
and how much this violates the providers
Hippocratic Oath. Yet when a MCR Advantage Plan
commits fraud, often amounting to tens of millions
of dollars, we read these reports, but there is
nothing in these reports accusing these criminals
of stealing, nor threatening the Medicare trust
fund. The amount stolen is in small print rather
than headline news. All of these criminal events
do in fact threaten the Trust Fund, no less or
more than providers who perform unnecessary
procedures and who overbill or bill for procedures
not performed. A drain on the system is a drain,
Period! There is little if any reports about
penalties and recoupments invoked to the company
or their executives.

Why is there a two-tiered justice system here?
CMS, if committed to following the money trail,
should be hard on the trail of these companies who
raked in record profits. But alas, CMS is afraid,
because if they banish these companies or too
harshly punish a MCR Advantage Plan from the
Medicare program, they lose the fight to get more
patients enrolled in the Advantage System. Thus,
CMS' lack of courage to go after the Advantage
Plan simply perpetuates and encourages these
criminals working for Advantage Plans to commit
more fraud.

CMS/OIG if you are listening, these MCR Advantage
Plans are threatening the Medicare Trust Fund
equal to if not greater than a provider who
collects $ for services not performed and its time
CMS/OIG and other Federal agencies take a stand
against these white-collar criminals. I as both a
provider and beneficiary of Medicare services want
this illegal behavior to stop! I don’t need to see
any more money spent on OIG studies until you
start punishing these companies with real
penalties, that not only punish them but send a
message to other actors in this area, that CMS
means business!

To providers, you should fight back, insist on
having the MCR Advantage Plan pay you a minimum of
$25/chart. They may not pay you but they also may
not receive the ammunition and statistics needed
to perpetuate this fraud. And do not fear their
threatening letters. Not one physician in any
state or specialty I have heard from has ever
stated that they were booted from a MCR Advantage
Plan because they refused to provide charts for
these data mining campaigns.

For more information on this latest audit see
Highmark MCR Latest to Commit MCR Advantage Fraud

Name Withheld

Other messages in this thread:

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10/24/2022    Judd Davis, DPM

MCR Advantage Plan Again Found with its Hand in the "Cookie Jar" (Paul Kesselman, DPM)

Dr. Kesselman, I too have a tough time
understanding why there is not more outrage and
commentary on this topic? My guess is that some are
afraid to speak up or mostly that people feel
powerless to do anything about these huge companies
defrauding the taxpayers of billions. Those
insurance companies have nearly unlimited funds and
likely have huge clout with our politicians on
capitol hill which may be why our government does
nothing to stop it? Corruption? We should all be
writing our congressmen to tell them how we
disapprove of these egregious activities, selling
any shares we may own in these publicly traded
companies, and switching our personal health
insurance plans to some that are not committing
this fraud, if there are any?

Maybe the next time Ciox requests their chart
audits we ALL refuse it, knowing darn good and well
that this is a ploy to up-code those charts so
United can get paid more. There has been some
recent talk on here of striking, doctors
unionizing... but only talk, no action. Without
action nothing will change. I think that if
something were organized most of us would step up
and band together, as we've reached our limit. As
I watch my practice get slowly eroded by declining
reimbursements from these insurers, while they
profit more and more each year, it is disheartening
to say the least.

Here's some numbers that will raise your BP, 2021
Net profit: United Healthcare(UNH) $17.3Billion,
Aetna(CVS) $7.9B, Cigna(CI) $5.4B, Anthem(ANTM)
$6.1B.

https://www.fiercehealthcare.com/payers/unitedhealt
h-was-2021s-most-profitable-payer-heres-look-what-
its-competitors-earned

Their profits have all soared during the pandemic.
Are any of these companies increasing your
reimbursements 8-10% this year to compensate for
inflation? I bet not. BTW Anthem is changing its
name to "Elevance", just like UnitedHealthcare has
"Optum". What's up with that?

Judd Davis, DPM, Colorado Springs, CO

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10/19/2022    Paul Kesselman, DPM

MCR Advantage Plan Again Found with its Hand in the "Cookie Jar" (Name Withheld)

A recent anonymously posted letter on PM News
really got me thinking and it actually played out
during a recent visit to my health club. Two
Medicare beneficiaries were discussing a recent NY
Times article, which had been published earlier
that day. One beneficiary commented that he
couldn’t believe that insurance companies were
actually paying doctors to put more diagnosis in
their charts.

I offered the correction that it was actually the
insurance companies and their data mining
companies which were defrauding the government and
threatening the Medicare Trust Fund. Over the next
few days, I received two stories from Becker’s
Hospital Review (October 10 and October 14), which
not only supported my opinions but went onto
provide an even greater fraud committed by just
about every Medicare Advantage Company.
I was astonished that the amount of fraud
committed by the most well-known third-party
payers in the Medicare Advantage program, which is
now estimated at about $600Million dollars for the
years 2011-2013. The numbers are even far higher
into the tens of billions of dollars for the year
2020. One can only imagine what it has been over
the last decade.

One company mentioned in the report, Elevance, is
facing charges of committing fraud by collecting
$100M in overpayments from 2014-2018. That’s $25M
annually for one small company. Who knows what it
is for the big players such as UHC, BC, Cigna,
etc.?

The Becker article entitled “How payers have
exploited Medicare Advantage names a physician who
is also former coding official for Kaiser who is
accusing the payor of significant fraud stating
that he was instructed by supervisors to find
additional illnesses that would lead to expensive
claims, by which to place patients in higher
paying tiers. The article further states the
following breakdown on these familiar companies
which are threating the Medicare Trust Fund:

•Accused of fraud by a whistleblower: UnitedHealth
Group, Humana, Kaiser Permanente, Cigna, SCAN
Group
•Accused of fraud by federal government:
UnitedHealth Group, Elevance Health, Cigna, SCAN
Group
•OIG says it overbilled: UnitedHealth Group,
Humana, CVS Health, Elevance Health, BCBS
Michigan, Cigna, Highmark, SCAN Group

Are these names familiar to you? Why are we the
providers enabling these companies to commit fraud
while they reimburse us sometimes less than 50% of
Medicare?

They are all as the anonymous writer suggested, an
absolute threat to the Medicare Trust Fund. Far
greater than all those indicted by the Medicare
Strike Force.
Perhaps all this extra cash that these big
insurance companies have raked in over the years
is paying for their aggressive marketing campaigns
often provided by well-known and well compensated
celebrities.

I agree with the anonymous poster, that unless CMS
and the Federal Government start prosecuting these
companies and hold their CEO and their data miners
such as Citrix and others accountable, this fraud
will only escalate. This will leave us the
taxpayers, providers and Medicare beneficiaries
left to pay the bill. For these crimes. It’s high
time, CMS and the OIG haul these companies and
their 7-figure salaried CEO into court and place
them in the same living quarters as they would
place physicians who threaten the Medicare Trust
Fund. Just because these executives don’t carry
weapons and rob people at gunpoint or wear white
coats, doesn’t mean they don’t deserve to be
fitted with orange jump suits.
I ask my colleagues where is your outrage? Why has
this not garnered more commentary on PM News and
elsewhere in print. Are you that afraid to speak
out?

Apparently some Congressional Representatives are
in fact fed up and on October 17 Two U.S.
representatives have introduced a bill that would
rename Medicare Advantage plans, prohibit private
insurers from using "Medicare" in plan titles or
advertisements and impose "significant fines for
any insurer that engages in this deceptive
practice."
Rep. Mark Pocan, one of the bill's two Democratic
sponsors, said Medicare Advantage programs provide
"pale alternatives to what Medicare does" and
undermine traditional Medicare.
For more information read:

https://www.beckerspayer.com/payer/how-payers-
have-exploited-medicare-advantage.html?
origin=PayerE&utm_source=PayerE&utm_medium=email&u
tm_content=newsletter&oly_enc_id=8252G7870912J6C
and

https://www.beckerspayer.com/payer/bill-would-ban-
payers-from-selling-medicare-advantage-plans-
under-medicare-name.html?
origin=PayerE&utm_source=PayerE&utm_medium=email&u
tm_content=newsletter&oly_enc_id=8252G7870912J6C

Paul Kesselman, DPM, Oceanside, NY