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09/04/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Doug Richie DPM
The federal government killed a plan in 2014 which would have discouraged Medicare Advantage health insurers from overcharging by reviewing patient records for additional diagnoses. CMS apparently dropped the regulatory plan after an "uproar" from the insurance industry.
As a result, Medicare Advantage plans continued to overcharge Medicare for unsupported diagnoses based upon chart reviews for at least $5 Billion per year over the next ten years.
Doug Richie DPM, Long Beach, CA
Other messages in this thread:
11/15/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Elliot Udell, DPM
The adage "there are no free lunches" applies to Medicare Advantage plans. These plans are promoted all day long on television. They promise people the world. Patients are not aware of what they are not going to pay or how little they will pay their doctors, forcing them not to take patients on these plans.
I belong to an upscale gym. My secondary pays the entire tuition, and hundreds of people go to this gym because it is "free." Two weeks ago, they sent out a mass letter letting people know that most Advantage plans will not cover the monthly dues, and people will be required to pay $150 a month to continue their membership. The manager of my club told me that the insurance companies who offer the Advantage plans are dropping paying for gym memberships. It was not the club's decision.
Perhaps we should make our patients aware of what they might be losing if they switch to these plans.
Elliot Udell, DPM, Hicksville, NY
11/02/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Ron Werter DPM
Just a thought right now. Sending the report by the government back to the insurance companies instead of the charts they ask for.
Ron Werter, DPM, NY, NY
10/29/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare "Advantage": Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions
From: Paul Kesselman, DPM
I, along with others, have posted a myriad of references to the sham that is Medicare Part C. This recent publication, OIG Cites Billions Wasted on Health Risk Assessment from the OIG is the most infuriating of all recent reports. When will our Congressional reps finally realize that this program must end? The issue here from a political perspective is that it won't unless we, the public, impeach our Congressional delegation who support this program. Where is their job security if they are not re-elected?
I'll admit I am naive because this likely won't stop unless the billions in political contributions from the large insurance companies, which foster these programs, is cut off. Physicians also shoulder some responsibility. It's time to simply refuse to cooperate with those companies which ask us for charts. You are under no legal obligation to provide this information. No charts, no data. Simple fix. I also have seen many health systems take the bull by the horns and simply toss their contracts with these programs out the window.
I know it's easy for me to say all this because I no longer rely on income from seeing patients, but if I did, I hope I would have the fortitude to say enough is enough! The OIG report, is accurate but will it result in any real action?
Paul Kesselman, DPM, Oceanside, NY
10/21/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Paul Kesselman, DPM
I was in practice for over 35 years and had the opportunity to share office space and staff with an internist. He and I became very close and I developed a very keen awareness of the pressures these generalists faced when referring patients to any specialist, not just DPMs. Thus, I saw first-hand the valid issues presented recently by Dr. Jacobs. I am sure he would agree, that does not give the insurance companies the right to pay for substandard care, nor does it alleviate the legal, ethical, and moral responsibilities of the referring physician to get their patients to the right specialist in a timely manner. And simultaneously it does not alleviate the responsibilities of the treating specialist to provide the proper care. Yes, there are theoretical and practical matters at stake here, as Dr. Jacobs duly noted, and walking that line is often a tightrope, but nevertheless everyone in this game, including the patient, must be involved in negotiating these hurdles.
This topic has gotten so heated that a recent U.S. Senate report on this matter was released yesterday and is available at: U.S. Senate Hearing Bashes Medicare Advantage Plans for Using P/A as a tool to boost profits. This report singled out the largest Medicare Part C plans, not just one, and cited 10 takeaways, which I urge everyone to read. What strikes me is that less than 10% of denied prior authorizations were appealed. The report does not reflect how many initial denials were overturned and the eventual health costs to the patients, who may have ultimately paid the price. Hopefully, this is a good start in dismantling a system which is in fact costing the taxpayers more money!
Paul Kesselman, DPM, Oceanside, NY
10/17/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Allen Jacobs, DPM
With regard to the denial of services by MCR Part C providers, there is a practical aspect which cannot be denied. Dr. Kesselman notes that in theory, by the "letter of the law", Medicare Advantage plans are obligated to provide services normally provided to a patient as defined by the local LCD or national directive. However, many in private practice rely on referrals from physicians and physician-extenders for practice survival.
Increased podiatric costs are considered a loss of profit to the referring healthcare provider. The referring Medicare advantage plan healthcare providers monitor payments to providers to whom they refer. Sadly, unethical referring healthcare providers will remove or discontinue referrals to those whom they perceive to be...
Editor's note: Dr. Jacobs' extended-length letter can be read here
10/16/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Paul Kesselman, DPM
It seems that not a day goes by without another MCR Part C plan being accused of fraud or abuse for any number of reasons. The main issue for most providers is that despite them supposedly being legally obligated to follow the fee-for-service MCR LCD for their prior authorization requirements, they often do not. Dr. Purdy's case in point, the patient had a TMA and now requires a toe filler (L5000); this should be a no-brainer based on the lower limb prosthetic LCD.
Despite his obtaining a P/A for this particular case, the claim was still denied. This should never be allowed and fortunately recently passed legislation now enforces P/A requirements of these "Advantage" plans to follow...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/12/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Jon Purdy, DPM
Is it any surprise that capitated advantage plans would decapitate the physician? Nobody knows more than physicians, the purposeful and frankly unethical denials of these plans. The study found exactly what we already know. When every piece of documentation is in place and every last medically necessary criteria is met, and that is met with a denial, there is obviously a problem.
In my case a patient with a forefoot amputation was denied an L5000, even after prior authorization was obtained. The study went on to recommendations of “guidance and retraining.” Is that any surprise? How about fines and threats of pulling them from the system? Even better would be CMS intervening on the physician’s behalf. How about reversing these non-payments and egregious denials? How about a class action lawsuit by physicians? If physicians don’t “act right”, we are subject to possible legal action and removal from the system. When CEOs start going to jail, then we’ll be getting somewhere.
Jon Purdy, DPM, New Iberia, LA
10/10/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare Advantage
From: Paul Kesselman, DPM
A recent Medtrade News (a publication of the DME industry) contains a scholarly article from two attorneys targeting the Medicare Advantage Industry. These two attorneys have represented many DME suppliers (and perhaps DPMs) in their battles with the various Medicare Part C plans. The article also discusses a recent OIG report on the MCR Part C industry. More information on both Medtrade and the OIG report can be found here.
These two articles are a must read for every practitioner, regardless of degree or specialty.
Paul Kesselman, DPM, Oceanside, NY
09/05/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Paul Kesselman, DPM
Dr. Richie is 100% accurate in his posting. To say that there have been many posts on this issue both here and in many medical publications nationwide would be an understatement. Unfortunately recent court cases have heavily favored the insurance industry and there is almost no sign of the fraud referred to as Medicare "Advantage" going away. This despite recent stories which have appeared in the news illustrating the amount of fraud both large and small Medicare Part C plans have committed.
The government has made it clear they want to pay a set fee to insure seniors and entirely transfer the financial risk to the insurance carriers. This is despite the fact that studies (aside from the fraud on data mining) have stated: Privatized senior care offered by Medicare Advantage insurance plans has led to higher costs for Medicare and is a drain on the Medicare trust fund.
There are several ways to kill the fraud: One is to outlaw insurance sponsored political campaigns; second is for medical providers to stop providing data which they are not legally obligated to provide; and the third is to decide whether or not you can afford to provide care to patients with reimbursement at 50-75% of Medicare rates. The latter, of course, have decreased about 30% adjusted for inflation over the last decade. Perhaps providers are both part of the problem and the solution.
Paul Kesselman, DPM, Oceanside, NY
05/08/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MA Plan Extras on the Chopping Block
From: Paul Kesselman, DPM
In today's issue of Becker's Health Care there were several issues regarding MA plans mentioned. Aside from some reiteration of the news last week that Humana will be leaving the MA market in some areas starting Jan 2025, others announced that some "extras" which MA plans offer over traditional fee for service would be chopped. Why? Because CMS has finally wised up and cut the tiered reimbursement structure which MA plans receive as a monthly stipend from these plans. Perhaps CMS has finally wised up that these plans have been stealing billions of dollars in taxpayer revenue by falsely massaging our data and elevating the risk strategy.
As one MA CEO stated, they are prioritizing profits over members and will be leaving the market in certain areas where they can't make a profit. Others refuse to say which "extras" will be cut as it's too early to predict this for 2025. But you can bet expensive extras such as dental, transportation, and food services will likely be cut. This is exactly what the government will get when they turn Medicare over to privately owned companies to run Medicare.
Paul Kesselman, DPM, Oceanside, NY
03/06/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medical Advantage Update
From: Paul Kesselman, DPM
In a recent issue of Becker's ASC Review, 5 more newsworthy stories regarding Medicare "Advantage" Plans appeared. This includes issues regarding delayed access to care (22% for MA vs 13%) for traditional Fee for Service Medicare, fines due to delays in providing mail order medications, one healthcare system dropping Humana and Aetna, another suing Humana, and lastly, a JAMA study showing that MA enrollees receiving less intensive post-acute care as compared to beneficiaries in traditional Fee for Service Medicare.
Paul Kesselman, DPM, Oceanside, NY
03/04/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE) - PART 2
From: Mark Spier, DPM
The former chief of CMS has confirmed what most of us already know. Medicare Advantage programs use chart review and up-coding to obtain huge profits. Meanwhile we, the plebeian providers, are still subjected to the crippling sequestration which diminishes the already meager payments we receive. Read the full length article here.
Mark Spier, DPM, Reisterstown, MD
03/04/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE) - PART 1
RE: Medicare "Advantage" Continues to be Disadvantageous
From: Paul Kesselman, DPM
In a recent article, it is projected that Medicare "Advantage" costs will continue to be problematic and result in premium increases to policyholders as well as an increase in costs to beneficiaries for those "extra" benefits not covered by traditional fee-for-service Medicare. For more information click here.
Paul Kesselman, DPM, Oceanside, NY
11/23/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MA Plan Overpayments
From: Paul Kesselman, DPM
A recent survey conducted by CMS illustrated that Medicare Part C continues to reap the gravy train provided by CMS to the tune of $16.6B in improper payments in 2023. CMS, to its credit, has finally started to put some teeth into their penalties. Over the last few months, it has increased penalties so they are not comparable to parking tickets to the likes of UHC or Humana.
More recently as one MCR Part C official for Cigna found out, she may be facing criminal felony charges with potential for prison as her next gig. If CMS is to ensure the integrity of this program, they can't simply look the other way when insurers commit fraud. If they don't do it for healthcare providers, then they should be imposing similar penalties for those who occupy the C suite at these mega insurance carriers. Otherwise, we will all wake up one day asking where did all the money go? For more on this story, Click here.
Paul Kesselman, DPM, Oceanside, NY
11/13/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: 14 Insurers Leaving Medicare Advantage
From: Paul Kesselman, DPM
A recent article in Becker's Healthcare revealed that 14 payers are exiting the fraudulent filled Medicare Advantage Market. While some other big movers and shakers will no doubt fill their shoes, perhaps the tide will soon be turning as criminal investigations directed against individuals such as Medical Directors of MA plans are pursued by HHS and OIG.
Here in NY, Catholic Health Systems, a large privately-held medical group to Optum's Pro Health and which has thousands of patients, announced they are leaving the MA market. Hopefully, this is the initial shot across the bow. We can only hope that the future of Medicare is not with private equity companies and the government will no longer tolerate being ripped off.
Paul Kesselman, DPM, Oceanside, NY
10/09/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Jack Ressler, DPM
I am not surprised about the treatment/harassment Dr. Dellinger received from Cigna. Harassment like this should be reported to the insurance commissioner of his state. As for the $30 per chart he requested, that amount is too low. Fifty dollars per chart and more should be the universal amount charged. They will not pay it and you will avoid having you or your staff strapped with the tedious task of chart preparation especially if a high number of charts are requested.
Jack Ressler, DPM, Boca Raton, FL
10/06/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: R. Alex Dellinger, DPM
It is incredulous to me that these "plans" (I love that Dr. Kesselman won't use the 'A' word. I have felt that way since these plans' inception!) continue to get these huge fines; however, we don't read about their CEOs (who I have no doubt know exactly what their business is doing) getting sanctioned, charged with any crimes, etc. All the while, doctors who play by lesser criminal rules face jail time, fines, and license revocations (of course doctors shouldn't cheat either).
I would like to share something interesting that happened to us: my group also gets nearly weekly requests from these plans requesting records. We have always requested payment ahead of time. Most, after some hemming and hawing, eventually pay and we send records (we charge $30 /record). However, a recent one caught my attention with one particular "plan". After requesting payment for a records request, they were ADAMANTLY against paying, and literally threatened that it was a violation of our contract to withhold the records. They insinuated that they would "report us" if we didn't send in the records (even though they never mentioned to whom).
Luckily, I have many lawyers in my family, and had one write a letter back. We advised them to provide a copy of the contract where they think we had to provide records (our contract with them said no such thing). We also advised them that threatening language toward us wouldn't be accepted, and that if they continued that rhetoric, we would report them to CMS, and the insurance commissioner of our State. Within 7 days, we received a check for $30, times the number of charts requested.
R. Alex Dellinger, DPM, Little Rock, AR
10/05/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE) - PART 1 A
From: Paul Kesselman, DPM
Well another one bites the dust. This is just another one of those MCR Part C (Medicare Replacement, I don't dare say the word Advantage) who continue to skirt the rules and make money off the taxpayers. But the patients are going to continue to seek out these plans since their mighty pocket book tells them to do so and Congress really wants patients off the FFS MCR roles so the Feds can shift risk to the private sector.
There is a way to fight back, but doctors clearly are inept to do so and will continue to either retire from clinical practice, become indentured servants to large corporations, or the few smart ones will go fee-for-service and not accept any insurance.
When will the medical profession wake up? If your neighborhood UPS driver can get a base salary of $'175K + benefits and thus avoid striking, I don't think it's too much to ask for doctors to obtain a raise once a decade (at least)!
Paul Kesselman, DPM, Oceanside, NY
06/30/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare Advantage Plan Expenditures
From: Paul Kesselman, DPM
As a follow-up to my recent letters regarding Medicare Advantage Plans and where all the money CMS pays them goes (and doesn't go), recent postings from several Medicare Advantage Plans advertised openings for a Director of Medicare Risk Adjustments. The salaries paid range from mid $150Ks to the mid $300Ks, and the CEOs of these companies have base salaries of no less than $8M, with some having 8 figure salaries.
In comparison, most medical directors of Medicare contractors are paid far less in the mid-$200K range, equivalent to what many MDs/DOs are making. The point is that it pays to go to business school, get an MBA, and 6 years post high school, you can go to work for a Medicare Advantage Plan (and that is perhaps where the Advantage name is correctly used). These individuals have the potential to be making enormous salaries with much less debt and far more working years, during which you can be funding retirements, your children's education, etc. So now do you wonder where the $ is?
Paul Kesselman, DPM, Oceanside, NY
02/18/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: CMS Implements Tougher Medicare Advantage Audit Rule
From: Paul Kesselman, DPM
CMS will implement stricter audits of Medicare Advantage plans, a move that could leave payers on the hook for billions of dollars in repayments to the federal government. In a final rule issued Jan. 30, the agency said it will strike the fee-for-service adjuster from risk adjustment data validation audits, which would have calculated a permissible level of payment errors and limited audit recoveries to payment errors above that level.
While this current action is less stringent than the initial plan CMS previously formulated, it nevertheless is CMS' reaction to many Medicare Advantage Plans having been audited and found cheating on data mining.The full story can be read here.
Paul Kesselman, DPM, Oceanside, NY
02/13/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Requests for Charts for Medicare Advantage Plans
From: Richard Rettig, DPM
Medicare Advantage plans hire private companies to glean our charts to mine data for better reimbursements. Many DPMs here complain bitterly of the burden. For many of us, a request for 200-300 charts with a decent reimbursement is a great bonus. However, either way, this entire process is likely coming to an end starting next year. There is a reason why these plans seem to love podiatry charts and pay well for them. They get a capitation upgrade for certain diagnoses. PAD is one of them.
Podiatrists have a tendency to diagnose PAD at a high rate, and that diagnosis is not often found in the primary care charts. In the 2024 CMS Feb 1st announcement, CMS is proposing dropping HCC code 108 (PAD) as a factor in Medicare Advantage capitation rates.The final announcement is April 3rd. If finalized, I doubt they will be requesting our charts in the future.
Richard Rettig, DPM, Philadelphia, PA
01/31/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Sequestration - Reduction in Federal Payment from Medicare Advantage Plans
From: Ron Freireich, DPM
I noticed on a resent ERA from Humana Medicare Advantage that there was a 2% reduction in the allowed amount due to the sequestration, remark code CO253. I was under the impression that only traditional Medicare was allowed to reduce our payments due to the sequestration.
Ron Freireich, DPM, Cleveland, OH
01/10/2023
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare Advantage Plans
From: Glenn McClendon, DPM
This is my biggest headache right now. With chronic denials of multiple charges, payment of only lowest value charge or failure to pay the EM code and procedure code on first and only visit, I'm powerless to combat these powerful insurance companies. This is where APMA should be directing some of their attention. With collapsing revenues from Advantage plans and potential legislative reductions upcoming, dues and ancillary expenses will be scrutinized heavily for effectiveness. Declining revenue always leads people/doctors to look for alternatives.
Please address this issue. I've considered telling these patients I'm limited to only an E/M visit on first presentation. Many PCPs already limit their E/M visits due to this factor. Will patients be mad? You bet. But performing the work and knowing you won't get paid makes me mad and catches up one day, and then you throw in the towel. So why not let the patient be unhappy and tell them to contact their penny pinching insurance company. When do we get some guidance about how to deal with this? If not APMA, then who?
Glenn McClendon, DPM, Conway, AR
12/12/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Double Standard for Medicare Advantage Plans
From: Name Withheld
The HHS OIG Fall 2022 report was recently released to Congress. On page 20, there are many referrals to seven inappropriate payments to a variety of Medicare “Advantage” Plans. Topping the list is Humana. The OIG claims that Humana in the time period studied falsified records to receive $34.4M worth of payments they received from CMS for risk diagnosis code risk assessments. If even half this amount is true, it is unconscionable that Humana is not severely fined, their executives terminated and subjected to criminal proceedings, and they should be banned from the Medicare program for ten years. This is no different from how other healthcare providers are criminalized, so the question is, why is the insurance industry treated different and preferentially when they commit fraud?
These OIG studies are great reads, but up until now, they have done nothing to stop the insurance industry’s abusive practices of denying “clean claims”, denying claims after prior authorization, ignoring CCI edits, “losing” charts sent for review and then claiming higher error rates to Congress, paying providers often less than 50% of Medicare, and this the last draw... falsifying data so they can be paid more from CMS. When will this madness stop? When will providers have the gumption to actually act out the famous quote, “I’m mad as hell and I’m not going take it anymore!” (from the movie Network), and Peter Finch it!
Name Withheld
11/30/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Glenn McClendon, DPM
My most frustrating issue for the past two years is dealing with payment from the Medicare Advantage or replacement insurances vs. regular Medicare. I'm sure all physicians are having the same problem. There are numerous carriers and all have myriad coverage provisions, different than regular Medicare even though they sell the product to seniors as a superior product to Medicare. I'm sure for some seniors they are somewhat improved, but I've rarely had a patient that felt improved by their product over Medicare when told he now owes a co-pay, etc. They are possibly less expensive, but there is always a trade-off. It seems ultimately that I'm the one losing income on these insurance products. I often find out too late when services are not covered or denied for some obscure reason.
My point: this may be a gargantuan task for anyone due to regional, state, or carrier issues. I would certainly attend online and possibly in person to hear anyone teaching, lecturing, educating podiatrists about specific and/or general algorithms in dealing with these Medicare Advantage denials. I would prefer dealing with a patient’s problem on an initial visit, like under regular Medicare, but could see myself having patients return later for non-emergent care when there is a question about coverage. Whose office can get pre-approval or find these answers while the patient waits in your exam room? I also have similar issues with Medicaid replacement products, maybe even worse.
So maybe some new CME lecture programs will incorporate this complex issue into their materials. I want to know if there is a new/better way to perform a common procedure or remedy a problem, but for now, I need to be compensated for what I'm currently doing.
Glenn McClendon, DPM, Conway, AR
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