01/29/2025    Paul Kesselman, DPM

More MCR Plans Violate the Law

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 financial burden.
• Elevance Health was fined $149,060 for
failing to comply with Part C requirements by
overcharging enrollees for medical services and
exceeding maximum out-of-pocket limits,
potentially increasing enrollees' financial
burden.
• Health Alliance Medical Plans and its
parent, Carle Health, were fined $101,500 for
violating Part C requirements by charging
enrollees more than the annual maximum out-of-
pocket limits, potentially increasing their
financial burden.
• Humana was fined $99,064 for violating
Medicare Part D requirements by failing to
reprocess prescription drug claims based on
enrollees' low-income subsidy levels within the
required timeframe, potentially increasing their
out-of-pocket costs.
• Molina Healthcare was fined $67,976 for
failing to reprocess Part D prescription drug
claims based on enrollees' low-income subsidy
levels within 45 days and for charging Part C
enrollees more than the maximum out-of-pocket
limits, potentially increasing their out-of-pocket
costs.
• Baylor Scott & White's health plan was
fined $37,816 for violating Medicare Part C
requirements by overcharging enrollees for medical
services and exceeding maximum out-of-pocket
limits, potentially increasing their financial
burden.
• Medco Containment Life, a Cigna
subsidiary, was fined $32,364 for violating Part D
requirements by failing to reprocess prescription
drug claims based on enrollees' low-income subsidy
levels within the required timeframe, potentially
increasing enrollees' out-of-pocket costs.

Is that enough or will there be more tomorrow? Why
aren't the executives who dreamed up these schemes
being personally indicated and sent to jail. That
is the big question that I and many other
clinicians are asking. A physician loses their
livelihood over a few hundred thousand dollars
(and I don't disagree with them being punished) by
why are C-suite executives not being held
personally responsible? Until corporate America is
held responsible, this will continue as the execs
have no personal stake in the game! indicted and
subject to a prison sentence.
For more info please read:
https://www.justice.gov/usao-edmi/pr/health-care-
plan-agrees-pay-over-500000-part-self-disclosure-
potential-false-claims

Paul Kesselman, DPM, Oceanside, NY

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