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 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
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
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
11/28/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MCR Advantage Plan Audit
From Ron Werter DPM
After reading all the information about how the advantage care plans are really taking advantage of Medicare, I tried a new tactic last week when I mistakenly answered the phone and found myself talking to one of the third-party companies asking for chart review. I explained that I would be happy to comply, but since I read all about Medicare asking for money back due to the improper billing that has been done, I would need a letter from the insurance company certifying that they are not now under investigation from CMS and that all previous claims have been settled. I explained that I am an ethical practitioner and don’t want to participate in any way in any scheme that would be considered improper. They should send me the letter ASAP so they can get the charts in a timely manner.
Needless to say, someone else from the same company called three days later and left a message as if I had not spoken to anyone before.
Ron Werter, DPM, NY, NY
11/25/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MCR Advantage Plan Audit
From: Paul Kesselman, DPM
Newly released audits show Medicare Advantage plans overbilled the federal government by millions between 2011 and 2013, with some plans overbilling an average of more than $1,000 per patient per year, Kaiser Health News reported Nov. 21. CMS released the decade-old audits in response to a lawsuit from the news outlet. The 90 plan audits uncovered $12 million in net overpayments for the 18,090 patients sampled. CMS has said it plans to use these error rates to recoup an estimated $650 million in repayments.
Now can you imagine a specialty group of physicians having overbilled Medicare by that amount. How many physicians and administrators would lose their license, go to jail, etc. Where in this story does it indicate the carriers will be subject to False Claims Acts Penalties? That's the kind of penalty that would cause the UHC CEO to shed a tear!
What more will it take to prove that insurance companies promoting "Advantage" plans are now the wolves guarding the hen house?
Paul Kesselman, DPM, Oceanside, NY
10/27/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Chris Robertozzi, DPM
Medicare Advantage Plans’ deceit is the new game in insurance fraud. Back in 2007 or 2008 Aetna and Cigna were convicted of insurance fraud for not reimbursing their insurers for lab fees that were a covered service. The amount of money that should have been paid to insurers was over a billion dollars for each insurance company. Aetna and Cigna were fined $250,000 each and did not have to compensate the insurers for the money that was inappropriately withheld.
Of course, they were told to stop and desist that practice. When the CEO of Aetna was interviewed, his response was that it’s just a business decision. Two years later, they were back in court for the same thing. The outcome of that trial never...
Editor's note: Dr. Robertozzi's extended-length letter can be read here.
10/24/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Judd Davis, DPM
Dr. Kesselman, I too have a tough time understanding why there is not more outrage and commentary on this topic? My guess is that some are afraid to speak up or mostly that people feel powerless to do anything about these huge companies defrauding the taxpayers of billions. Those insurance companies have nearly unlimited funds and likely have huge clout with our politicians on Capitol Hill which may be why our government does nothing to stop it? Corruption? We should all be writing our congressmen to tell them how we disapprove of these egregious activities, selling any shares we may own in these publicly traded companies, and switching our personal health insurance plans to some that are not committing this fraud, if there are any?
Maybe the next time Ciox requests their chart audits we ALL refuse it, knowing darn good and well that this is a ploy to up-code those charts so United can get paid more. There has been some recent talk on...
Editor's note: Dr. Davis' extended-length letter can be read here.
10/21/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Eddie Davis, DPM
Kudos to Paul Kesselman, DPM for a great post concerning abuse of the system by Medicare Advantage plans. At first glance, it seems hard to understand how large health insurance corporations can get away with seemingly high overcharges to Medicare. It happened, in my opinion, because the system was structured in a manner that it allowed it to happen.
Medicare Part C was designed, presumably, as an alternative to traditional Medicare for the purpose of saving government funds. It did not do so from the beginning. CMS pays Medicare Advantage plans a fixed amount per month per patient signed up for the plans. That amount was never fixed at any significant discount to the average monthly traditional Medicare expenditure. Next, CMS allowed the plans to perform “audits” to show that the monthly payment was insufficient via a flawed formula. The plans could show that it has enrolled patients were sicker, perhaps subject to a higher intensity of care, but that was only on paper. The plans did not have to actually demonstrate that they had to provide a higher level of care. This has been going on for about 3 decades now! Either someone in government was ignoring this obvious issue or maybe they were on someone else’s payroll?
The Medicare Disadvantage plans could cherry pick patients. Did anyone actually compare intensity of care delivered to patients both in traditional Medicare and Part C? Many patients who are relatively healthy retirees initially enroll in Part C but then switch to traditional Medicare as they become less healthy and their medical needs increase. How about end of life care? It is well known that the largest percentage of healthcare spending occurs in and around patient end of life. What percentage of such patients are covered by Part C plans?
Eddie Davis, DPM, San Antonio, TX
10/19/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Paul Kesselman, DPM
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 diagnoses 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...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/07/2022
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MCR Advantage Plan Again Found with its Hand in the "Cookie Jar"
From: Name Withheld
A recently reported OIG study found that the Highmark Medicare Advantage plan was the latest in a slew of previously reported MCR Advantage plans to provide unsubstantiated data to CMS. This data was then used to obtain higher payments than they were supposed to receive ($800K) from CMS for managing their MCR Advantage Plans for the time specified in the report. What is the source of the data which is fraudulently manipulated? Its source is from providers and the charts we elect to provide to the carrier, which the carriers then change and submit to CMS.
There have been relatively few complaints posted in many podiatric and other medical forums in comparison to the barrage of requests from MCR Advantage plans. However, when I speak with most doctors (MD/DO/DPM) they all acknowledge they have complied with these endless requests, ...
Editor's note: Name Withheld's extended-length letter appears here.
