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

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