10/16/2024    Paul Kesselman, DPM

Medicare Advantage in the News (Jon Purdy, 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 to the letter of the
law the LCD of their Medicare fee-for-service
Contractors. My advice to Dr. Purdy is to appeal
this to the ALJ if necessary. Simply reviewing the
medical chart with the LCD and having the P/A
should result in a positive outcome. It is truly a
shame that one would need to commit to this 3rd
level of appeal but I would never allow any
contractor to get away with this!

As for how can these contractors get away w/fraud
and abuse, which would have us as providers end up
in jail? Its because the playing field is not
level and the Federal government is in bed with
these contractors. Two decades or more ago when
the Part C plans were invented, the field was
skewed in favor of the insurance industry, so as
to incentivize them to take the risk off the back
of the government. Needless to say, some smart
actuaries also figured out that by simply placing
patients in a higher risk bracket , would net
their company has a higher ROI. This caught on
like wildfire and the government has been mostly
reluctant to prosecute the insurance company
executives for this fraud and abuse, despite clear
evidence of massive widespread fraud.

Let your Congressperson know that this has to
stop! I dare say this again, it is the providers
who let this go out of control. Stop providing the
diagnostic criteria you are not contractually
obligated to provide and think twice about working
with these plans which are overly abusive.

Paul Kesselman, DPM, Oceanside, NY

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