10/04/2023 Chris Seuferling, DPM
Hospitals Dropping Medicare Advantage
Here in Oregon, we’ve been dealing with HealthNet
MA plan since 2016 RE: modifier -25. Over these
past 7 years, Oregon DPMs have lost thousands of
dollars in denials, hundreds of hours of time, and
countless administrative burden to submit
appeals/paperwork, etc. to “win” a battle with ONE
insurance company for ONE code. Finally, this year
we had a breakthrough (after hundreds of emails
and multiple meetings with HealthNet ) and thought
we resolved the issue. We were giving each other
high fives and pats on the back for a job well
done. Then last week, I received EOBs from 2
HealthNet patients denying payment for office
visits. So, here we go again. Same as it ever was.
We call it a “victory” when we win an appeal for
money we should have been reimbursed in the first
place. I call it DISGUSTING and CRIMINAL. Money is
being stolen from us every day! I followed APMA’s
guidelines and played by the rules, but I’m sorry
folks…it’s not working.
Currently, I am the Oregon CAC/PIAC Rep and most
all of the complaints we are dealing with are MA
plan related. Issues that would be resolved if
these plans truly followed CMS guidelines MA
plans have no oversight, CMS won’t intervene, your
legislators don’t care, and dropping out of MA
plan network does not fix the problem. I’m sorry,
but after being involved in these issues at a
trench level, the only viable solution I see is
LITIGATION. The problem is top down and not at
the rep or medical director level and
unfortunately the only way to get CEO attention is
with a lawsuit.
I’ve been told “No, Dr. Seuferling we don’t
recommend litigation. Lawsuits are messy, long,
and expensive”…but I’m sorry, so is our current
approach. How effective is what we are doing now?
Spending 7 years to solve one issue with one MA
company and now I get to do it again…and then
fight the same battle with United Healthcare,
Aetna, Regence, Humana, etc….a never ending Whack-
a-mole game.
In November, we have our annual APMA CAC/PIAC
meeting to discuss these issues. I would much
rather take the thousands of dollars spent on this
meeting and use it towards litigation. MA plans
are our biggest insurance problem right now and
playing nicely is not working. I’m not a
litigious person by any means, but in my opinion,
we (APMA, State Associations, Providers) have been
way to soft and nice dealing with these insurance
companies. We need to collectively be more bold
and aggressive in our approach.
Strategically, we don’t need to litigate ALL MA
plans. Rather, I recommend we combine our
national and state resources/monies to go after
one MA plan and fight for transparency, following
CMS guidelines, back pay for lost reimbursement,
administrative burden, and fair parameters moving
forward. Will we get all that? Likely not.
However, I believe in court we have a good chance
to expose the criminal nature of these MA plans
and the negative impact they have on patient care.
Once victorious, we can set a legal precedent to
deal with future MA plans.
Personally, I would much rather spend my money and
time in this direction than continue to chase our
tails and step over dollars to pick up dimes.
Does anyone see an alternative solution?…besides
previous suggestions of dropping insurances and
going to cash pay model, or unionizing….which I
don’t see as feasible from a logistic standpoint.
Chris Seuferling, DPM, Portland, OR
