01/01/2025    Paul Kesselman, DPM

NY Medicare Advantage Insurer and CEO Will Pay Up to $100M

To say it's about time is an understatement. In
yesterday's Wall Street Journal, an article
titled: "UnitedHealth’s Army of Doctors Helped It
Collect Billions More from Medicare" is a must
read for every provider, patient and taxpayer. One
example cited, was a $16,200 payment vs. a $4,680
payment made by CMS to UHC for a 75-year-old male
patient. This was accomplished simply by adding a
few ICD-10 codes to the patient's risk assessment.
This clearly happened hundreds of thousands of
times in unwarranted scenarios. The study also
cited how the costs to CMS increased significantly
for those patients who went from fee for service
to UHC Part C plan.

The story also recounts the epics of one UHC
employed family physician at one of their numerous
Optum centers. This provider tells the story that
the EHR software would not allow him/her to close
out the patient's EMR unless the doctor added one
of numerous erroneous diagnoses, that would place
patients into a higher risk category He stated
that the company (referring to UHC) frequently
prepared a check list of potential diagnoses
before they ever laid eyes on the patients.

This one doctor eventually quit as an employed
physician and went into private practice. How many
other family physicians are facing this same
pressure? How many other insurance carriers have
similar practice requirements?

I totally understand the government's attempts to
offload risk (that's what insurance is), but fraud
is fraud no matter who commits it. If any
healthcare provider committed the level of fraud
alleged in this report (and there are others) they
would be placed in orange jumpsuits and banned
from the healthcare industry.

Rather than making the stockholders, executives
and trustees of these companies wealthier, think
of what the billions of dollars could have paid
for in terms of providing real healthcare
services! As more stories like this hit the lay
press, perhaps the politicians will eventually
have to listen and put a stop to this!

Paul Kesselman, DPM, Oceanside, NY

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