12/14/2022    Paul Kesselman, DPM

Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers By Millions

It is good to see stories like this in the
mainstream media and to see U.S. Senators
sufficiently irate to call CMS into question the
seriousness of these allegations. The $1,000 annual
overcharge per patient quoted by the anonymous
poster is actually quite higher, with one well over
$5,000 per year. Senator Chuck Grassley has called
for “aggressive oversight” to recoup the
overcharges, further commenting that CMS must
aggressively use every tool at its disposal to
ensure that it's efficiently identifying Medicare
Advantage fraud and working with the Justice
Department to prosecute and recover improper
payments.

The article further states that CMS has estimated
the total overpayments to health plans for the
2011-2013 audits at $650 million, yet how much it
will eventually claw back remains unclear.
It is unfortunate that this NPR story may have
initially drawn the attention of an investigator
due to fraudulent claims initiated by a now defunct
podiatry practice. If the podiatrist and their
administrators committed fraud, they should be
fitted with orange jump suits. In another story
today in Becker’s Spine Review, a neurosurgeon was
sentenced to 5 years in prison for accepting only
$3.3M in bribes.

It seems fair that the same treatment needs to be
doled out to the insurance company MBA, CFO, CEO
and all the other business executives who often
make 7 figure salaries and additional bonuses. It’s
high time they paid equally for their crimes and
CMS has the money restored to its coffers. These
are criminal actions which threaten the Medicare
Trust fund as much as those of fraudulent
healthcare providers! $650 Million dollars for the
two-year period 2011-2013. It’s anybody’s guess
what it’s up to now!

As the NPR story says this is not a partisan
political issue! They are absolutely correct! This
is a story that is front page newsworthy and every
American Taxpayer and those on Medicare (Advantage
Plan or not) should be concerned about. I would
urge APMA and other medical associations to start a
letter writing campaign to Senators and House of
Representatives members and insist on hearings and
court proceeding. When necessary, appropriate
criminal actions against these insurance carriers
need to be taken, including punitive economic
sanctions, jail time and banishment from Medicare.
Enough is enough!

Paul Kesselman, DPM, Oceanside, NY

Other messages in this thread:

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12/16/2022    Paul Kesselman, DPM

Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers By Millions (Michael M. Rosenblatt, DPM)

Unfortunately, Dr. Rosenblatt is correct. There no
doubt is a two-tiered system of justice in this
country. That does not mean we need to sit back and
accept it as it appears though many consumers and
providers have. Dr. Rosenblatt and his family have
had a similar experience that many of us have had
with insurance companies whether they deal with
long term care, health, life, disability,
homeowners, auto and all the various types of
insurance.

This issue, however, is a bit different. As opposed
to these nefarious practices dealing with
individual consumers who have little practical
recourse, the Part C Medicare Contractors have a
contract and fiduciary duty to report audit results
accurately and not with us individually but with
CMS. This agency has a great deal more teeth to dig
into any one entity no matter they be the “low
lying fruit” providers or megabillion dollar
corporations. It should not matter who the
criminals are should not matter!

From the practical perspective, the OIG and DOJ
will no doubt get more bang for their investigative
buck by pursuing the Advantage Plans than they
would ever get refunded from unscrupulous
providers.

Just think of the feather in the cap of the
investigative team who gets a mega billion-dollar
corporation to admit fraud and pay back hundreds of
millions of dollars to the US Treasury. How would
that infusion improve the future security of the
Medicare Trust Fund?

Hopefully, Congress will get the message that $450M
at a minimum and perhaps billions is nothing to
sneeze at! It should be far easier to get some or
most of that back from US based insurance carriers
than from unscrupulous providers who often hide
their money in unreachable off-shore accounts.

Paul Kesselman, DPM, Oceanside, NY

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12/15/2022    Michael M. Rosenblatt, DPM

Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers By Millions (Paul Kesselman, DPM)

Putting aside the very sad issue of a podiatry
practice that billed Medicare Advantage Plans
fraudulently, and their CEO is now sentenced to
prison, there is a vast difference between
fraudulent actions administered by various
corporate actors, when compared to individuals,
group practices and smaller entities.

Prosecutors are not interested in jailing CEOs of
large corporations (especially insurance companies)
for even proven fraudulent activities. Instead,
their efforts are placed into fines and attempts to
recoup funds. Even those are usually negotiated out
and relatively minor by corporate attorneys. Only
rarely are the insurance companies shut down. My
wife and I had a long-term care policy with a
company that went bankrupt. None of our funds were
returned, after paying in for about 10 years. The
CEO of the insurance company was granted an
enormous termination parachute, well into the
millions. He faced no prison time or even
prosecution.

Physicians on the other hand are "low hanging"
fruit for prosecutors since they do not have the
same political power as the insurance industry.
This is not to excuse their fraud, which brings
shame on all of us. While I do appreciate Dr.
Kesselman's call to action to bring about justice
against these corporate entities, I consider that
this effort will not bear fruit. The attorneys
representing these insurers will negotiate a
settlement with Government, which will also likely
include (but not mention) an enormous corporate
contribution to the political powers in Congress.
It is all "sleight of hand."

The Life Insurance industry pays-off Congress every
year to bring about certain tax savings for their
customers when they purchase life insurance offered
by that industry. I am not particularly against
this and have taken advantage of some of these
myself. But we need to be realistic: Our Country
has a two-tiered justice system, which is sometimes
political, sometimes apolitical. This was as true
during President Lincoln's Administration as it is
now.

Michael M. Rosenblatt, DPM, Henderson, NV