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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:
04/21/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Paul Kesselman, DPM
Interesting that in a recent article in Becker's Newsletter providing a detailed rationale for the cut in UHC stock price. Three Issues: The government cutting funding to CMS. This requires many lengthy discussions. The government is changing the risk model analysis, which while initially embraced by UHC in 2023, UHC is now rejecting. Many have been ranting about this for some time! Last, but not what needs to be addressed today, and here is the clincher, INCREASED UTILIZATION BY MEDICARE BENEFICIARIES.
In other words, their beneficiary population is getting older and using more services. So now it's the patient's fault that they are getting older and using more services? Did I read that right? They have the chutzpah (for those of you not familiar with the term that's the utmost in nerve) to blame it on the patients! You have got to be kidding! That many carriers thought this would never...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
04/18/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Allen M. Jacobs, DPM
Dr. Kesselman has offered a concern and has advised precaution in referrals to interventional radiologists, interventional cardiologists, and vascular surgeons. My experience over the last 2 years would support his warning. I have had the occasion to review multiple litigation scenarios in which a podiatrist has been named in a suit, rightfully or wrongly, for alleged inappropriate referral to interventionalists.
In some circumstances, podiatrists have entered into co-investment agreements with free-standing cath labs, somewhat similar in structure to that typically constructed with surgical centers. At least one national chain of such cath labs, offering stock and investment opportunity for the podiatrist, has come under federal investigation. Lawyers are aware that the podiatrist stands to benefit financially with increased use if...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
04/16/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE) - PART 2
From: Paul Kesselman, DPM
I couldn't agree more that it is absolutely ludicrous that the big business entities of medicine continue to get fat increases and patted on the back (even though many of their executives are guilty of participating in fraud in the billions of dollars...data mining). But this fight is not for just DPMs; it's about the survival of every healthcare provider, DPM, MD, DO, and all others who bill third-party payers. Dr. Brisbee and APMA cannot afford and should not fight this alone. In fact, this is not even organizational medicine's fight. We need a grassroots effort by all healthcare providers to fix a broken system from the ground up.
Until that happens we will be stuck with an antiquated system which simply does not work for patients and for which all healthcare providers will continue to be disenfranchised and not properly compensated!
Paul Kesselman, DPM, Oceanside, NY
04/16/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE) - PART 1
From: Ivar E. Roth, DPM, MPH. Jim Shipley, DPM
I see so much abuse with grafts and now revascularization procedures. I wish our profession would just do what is in the best interest of the patient and not the doctor’s pockets. I know it is tough out there taking insurance and that is why I advocate for podiatrists to take up the direct pay practice. Get off the insurance drugs and live clean and free again.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
I just wanted to respond to the posts regarding LE revascularization procedures performed by interventional cardiologists and radiologists. Half of the practices I'm privileged to be associated with reside in rural communities. Every time that we needed to refer to vascular for a consult, and hopefully revascularization, our patients were put on a 6+ month waitlist that almost always seemed to end up in BK amputations with no revascularization even attempted.
This is their profession and not mine and so I don't desire to...
Editor's note: Dr. Shipley's extended-length letter can be read here.
04/15/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: OIG and Potential Abuse by Medicare Part C Plans and Lower Extremity Revascularization Procedures
From: Paul Kesselman, DPM
In a recent ICD-10 Monitor, some very strong allegations were presented concerning the abuse of Medicare Part C plans. The OIG is finally stepping up to the plate to ensure that these private traditional fee-for-service replacement plans follow the rules. The story estimates that over 9% of the tiered structure payments from CMS to these organizations are not supported by the patient's (your) charts and thus the additional amounts the Part C plans charged to CMS in upgrading schemes is also unsupported. It's about time that the investigative/enforcement arm for CMS got themselves involved. Perhaps they need to also investigate the billions of hard-earned taxpayers dollars it is estimated that these plans are paid in excess of what traditional fee-for-service Medicare would have cost for the same services.
The other part of this story has to do with revascularization procedures to the lower extremity. While DPMs do not perform these, we often refer these patients to our MD/DO colleagues who do. These procedures are no longer limited to being performed by vascular surgeons, as they are often performed also by interventional cardiologists and interventional radiologists. The take home point here is to be careful about who you may be referring these patients to, lest you get caught up into something less than ethical. As great as this sounds, I am also wondering what impacts the closure of Regional HHS offices and the loss of 20,000 HHS employees (10,000 terminated and 10,000 taking early retirement) will have on this and other HHS/CMS functions.
Paul Kesselman, DPM, Oceanside, NY
04/09/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MA Advantage Plans Get Increase
From: Farshid Nejad, DPM
Our leaders are failing us. How do MA plans get a 5% bump and all private practitioners are getting a 4% cut. This is ludicrous. Even more insane is providers accepting the terms of MIPS. If CMS wants information, they should bonus those who participate. Medical companies are being purchased for billions not just in the private equity arena but also by conglomerates like Amazon. We are not getting paid to participate but rather penalized by 9% if we fail to participate. I challenge newly elected Dr. Brooke Bisbee and her board to make this a priority.
These complaints about the egregious acts of CMS have been posted many times with calls to unionize. Quite frankly, we just need to grow a couple and tell lawmakers that enough is enough. This is unsustainable. We need to work with AMA and all the other associations including DOs, physical therapists, etc. to stop the wasteful spending into MA programs and re-invest in us. APMA, don’t brag about reducing Medicare cuts; we want the next media release to be about a positive pay increase equal to or greater to the inflation rate. The floor is yours APMA…show us why we pay our dues!
Farshid Nejad, DPM, Beverly Hills, CA
03/17/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: MCR Part C to be Paid $84B in Overpayments in 2025
From: Paul Kesselman, DPM
In today's Becker's Health Newsletter, Medpac announced that the MCR Part C industry will be handed over $84B in overpayments this year. This includes paying more for patient care than if the patient was in a traditional fee-for-service plan and the ever-present upcoding patient data to secure a higher monthly payment from CMS.
Now think about this, how many federal employees’ jobs could be saved with $84B? How many more patients could CMS afford to save if proper preventative healthcare initiatives were instituted? One such way is to do away w/this absurd routine foot care LCD and enable every geriatric patient to see a DPM as needed for what is alleged to be "routine foot care". CMS continues to pay out billions of dollars to healthcare companies, fattening their stockholders and C-suite executives, who deny care and rake in profits. Physicians have endured a 20% or more reduction in pay (adjusted for inflation) over the past decade and Congress seems to be clueless to do anything. When will this madness stop?
Paul Kesselman, DPM, Oceanside, NY
01/29/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: More MCR Plans Violate the Law
From: Paul Kesselman, DPM
Here we go again, with MCR "Adv" plans and Now MCR Part D plans committing fraud. From the OIG: Commonwealth Care Alliance, Inc. (CCA) has agreed to pay $520,355.65 to resolve allegations that Reliance HMO, Inc., a company CCA acquired in 2022, violated the False Claims Act, 31 U.S.C. §§ 3729-3733, by providing cash payments to induce the referral of Medicare beneficiaries to enroll in Reliance’s Medicare Advantage Plan.
From a recent Becker’s:
• Centene was fined $2 million for violating Part C requirements by charging enrollees more
than the annual maximum out-of-pocket limits, potentially increasing their...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
01/20/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From Ron Freireich, DPM
This is beyond outrageous! Let me start by saying what a weak statement from the president of the AMA, with him ending his statement by saying, "it’s time for a new approach to physician payment reform.” No, a new approach is long overdue. Additionally, he states patient access will suffer if physicians close their practices. Why should physicians close their practices that we all worked so long and hard to build. He should have stated that physicians may start to drop out of Medicate Advantage plans and start charging patients cash if they want access.
We are all well aware of the massive fraud these Medicare Advantage plans are committing. The fact that CMS is rewarding the villain and penalizing the victim is unfathomable. The only conclusion that I can come up with is that there is something very nefarious going on and it should be investigated. In my opinion, the leaders in every medical association and the CEOs of every hospital across the country need to take action now as a united front.
Ron Freireich, DPM, Cleveland, OH
01/16/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare Advantage Programs Receive Boost While Physicians Wait: AMA
From: Chris Robertozzi, DPM
I agree 100% with the President of the American Medical Association, Dr. Bruce A. Scott’s, comment, “it’s time for a new approach to physician payment reform.” While Congress would need to approve it, physicians should be writing the reform. No one knows healthcare better than physicians who provide the care. The new approach should be that together, all the national healthcare associations rewrite healthcare completely.
The general population needs to know that we are on their side when it comes to providing healthcare. They should fully understand and know what physicians are recommending so they can compare it to whatever gets finally adopted. We must stand up for ourselves, otherwise we will continually be portrayed as the bad guy in this picture. We must take the lead. See www.betterhealthcarereform.com.
Chris Robertozzi, DPM, Newton, NJ
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
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