01/17/2023    Paul Kesselman, DPM

Request for 33 Charts for “Risk Adjustment” (Dave Williams, DPM)

It’s no secret that many doctors have some very
strong opinions which criticize the Medicare
Advantage Plans. Low pay, providing prior
authorization and then denying the claim, illegal
data mining and marketing campaigns which promise
the sky, these are just only a few of the issues we
should be screaming about when dealing with these
companies. It’s about time that CMS cracked down on
the advertisements and the dollars these companies
spend on those commercials. And in 2023, they will
need to have CMS vet those commercials prior to
allowing them to air.

A great way for CMS to get some dollars back and
that is to charge the Medicare replacement carriers
money to review their marketing campaigns at Fair
Market Value and tax the revenue they pay to the
media (have the insurance carrier pay the tax) for
these commercials. And how about some additional
transparency with how much they paid Joe Namath and
other spokesman or woman for their time?

The last transparency I would love to see (but
likely not going to happen) is for Broadway Joe and
others to vouch that they are a card-carrying
member of these Medicare replacement plans. They
will likely claim it’s a HIPAA violation. The
argument back is that if your plan is so wonderful
the truth of the spokesman personal experience
should be out there for everyone to see. We are not
interested in your list of meds or list of medical
issues. The public deserves to see that you so
believe in the product so much that you yourself
use it!

There is so little truth in these marketing
campaigns. Dental coverage? Really, does anyone
really expect the Part C plan to pay for a crown or
root canal, postings, etc. No, they will pay for
cleaning and x-rays, but if you have a real
problem, they may cover a tooth extraction and
after that, gum your food! And vision care, are
they really going to fork over a $500-1K for a pair
of transition and/or progressive glasses in a frame
that won’t break in a few months? And will they pay
for the replacement (nope same or similar).

Its readily apparent that the only people who
really sign up for these plans are those who fit
into several categories: Those who truly can't
afford to pay or don’t want to pay the premiums on
Traditional FFS Medicare and the required
Supplemental and Part D plans, those are forced
into them by employers, those who just get swayed
by Joe Namath and under celebrity appearances and
those just gullible to the media. Shouldn't the
gov't want to protect some of these beneficiaries?
In NYC there are several unions are in court engage
in a legal tussle mandating hundreds of thousands
of retirees into Medicare Advantage Plans, while
other unions are complicit with the transition
over.

Do you think there may be some corruption here as
well? If the carriers stopped spending tens of
millions of dollars on advertisements, perhaps they
would pay providers a fair market value for medical
services. If the carriers were forced to pay CMS
and the govt a fee to review their marketing
campaigns, you can bet they would be more carefully
reviewed. If all CMS is going to do is rubber stamp
the campaigns at a cost to the taxpayers, then
really have we gained anything?

As has been noted by many, why is it legal to
incentivize patients to join these plans with free
car services to their physician, food delivery, gym
memberships, etc.? If a physician did this, the
Feds would jump up and down stating the illegality
of it all as these are contrary to Stark and anti-
incentive laws. The real reason for all of this is
that CMS wants to get out of the insurance business
and privatize it. The replacement plan industry is
very profitable for these carries and have loaded
these carries balance sheets into the hundreds of
millions of dollars!

The solution to this problem really rests with each
provider!

Paul Kesselman, DPM, Oceanside, NY

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