11/18/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
From: Alan Sherman, DPM, Connie Lee Bills, DPM
Oh my goodness, the John Oliver segment about Medicare Advantage Plans that Paul Kesselman, DPM shared was just precious. Thank you for sharing one of the best pieces of satirical journalism I have seen in years. Every doctor should have this piece playing in their waiting room as a valuable service for their patients. Sometimes, humor is the best medicine and this one was certainly that. In the words of P.T. Barnum, there is certainly a sucker born every minute.
Alan Sherman, DPM, Boca Raton , FL
I agree what an amazing and informative piece! I learned something from it.
Connie Lee Bills, DPM, Mount Pleasant MI
08/04/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: Medicare Advantage (MA) Legislation in Congress: 7 Bills to Know
From: Paul Kesselman, DPM
In a recent Becker's Payer Issues there is a must read article for every doctor in the country. There are 7, that's right, 7 bills before Congress which will directly impact MA plans. One will require MA plans to pay the same as the fee for service Medicare. It actually has bipartisan support. There are a myriad of others which address prior authorization issues, data mining (several would actually outlaw it), and others.
If the proposed regulation requiring them to pay the same as the fee for service contractors is implemented, and the MA plans are taking the risk, how long do you actually think these plans will hang around? If the bill is enacted, how often will these claims be lost or never processed for a myriad of reasons by the MA plans? Perhaps legislation needs to be enacted along with this first proposed law which requires MA plans to pay clean claims (in accordance with Medicare Fee-For-Service) requirements.
Paul Kesselman, DPM, Oceanside, NY
08/04/2025
MEDICARE ADVANTAGE
UnitedHealthcare to Exit Certain Medicare Advantage Markets
UnitedHealthcare CEO Tim Noel offered investors a deeper look at the medical cost spike that's plaguing the insurance giant's finances. He said during the company's earnings call that pricing assumptions set by the company "were well short of actual medical costs" for 2025. UHC's current outlook, he said, instead reflects an additional $6.5 billion in medical costs, with more than half, or about $3.6 billion, coming from its Medicare plans.
Noel said that in MA specifically, the team is looking to adjust pricing and benefit designs to account for the cost pressures, which they anticipate will stretch into much of 2026. It has also decided to exit certain markets largely with plans that are more loosely designed, such as PPOs, in a move that will impact 600,000 beneficiaries.
Source: Paige Minemyer, Fierce Healthcare [7/29/25]
07/26/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: American Hospital Association Testifies at House Committee Hearing
From: Paul Kesselman DPM
This week, I had the pleasure of attending (virtually) a House Committee Oversight Committee meeting dedicated to issues with Medicare Part C Plans. Many organizations testified about the lack of transparency and the inconsistency of these plans regarding prior authorizations for medical treatment in and outside of the acute care setting, and the "peer" reviewers’ credentials and names being on these correspondences. The AHA called for a uniform set of guidelines for all MCR part C plans. This regards prior authorizations for medical/surgical treatment, clearing up delays in post-discharge from hospitals to post-acute care (SNF), and forcing carriers to reveal the names and credentials of those performing the prior authorizations and peer reviews.
Every ethical provider should be screaming for these uniform standards. This event was also covered by Becker's Health Care. And hooray for the judicial system which dismissed Humana's lawsuit against CMS regarding its downgrading of Humana's Star Rating, which Humana allegedly accuses CMS was improper. But many suggest that the real reason for the lawsuit was so that Humana could recoup some of the $M of dollars it lost in revenue due to this downgrade. What affect this may have for 2026 remains to be seen.
Paul Kesselman, DPM, Oceanside, NY
07/12/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE)
RE: DOJ Investigation of UHC Spreads To Former Physician Employees
From: Paul Kessleman, DPM
In yesterday's Wall Street Journal, an article appeared suggesting that the DOJ was speaking with former employees of UHC, including physicians, about allegations that UHC had pressured them to up-code diagnoses as part of a larger scheme. This was to increase CMS payments to UHC's Medicare Advantage Group.
The DOJ as part of a larger investigation along with CMS has announced they will be auditing every MCR Advantage Plan to ensure that these plans do not up-code their data mining in an attempt to inappropriately reap billions (you read it right) of dollars.
Paul Kessleman, DPM, Oceanside, NY
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
03/22/2025
MEDICARE ADVANTAGE NEWS
Cigna Exits Medicare Advantage Market
Cigna has completed the sale of its Medicare businesses to Health Care Service Corporation (HCSC) for a combined transaction value of $3.7 billion, the health insurers announced Wednesday. The deal gives HCSC Cigna’s Medicare Advantage, Medicare prescription drug and Medigap plans, along with CareAllies, a business that helps providers transition to value-based care. In total, it expands HCSC’s patients served from 22 million to 26.5 million, according to the company.
As for Cigna, the deal allows the insurer to fully exit a business that’s borne the brunt of rising costs and refocus on its core employer-sponsored coverage. Cigna plans to use proceeds from the deal to re-purchase shares and invest in its health services and health benefits businesses.
Source: Rebecca Pifer, Healthcare Dive [3/20/25]
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
01/15/2025
MEDICARE ADVANTAGE
Medicare Advantage Programs Receive Boost While Physicians Wait: AMA
“CMS has announced that Medicare Advantage (MA) plans are expected to receive an average payment increase of 4.33% from 2025 to 2026. Meanwhile, physicians treating Medicare patients are facing their fifth consecutive year of payment cuts — this time by 2.8% — despite practice costs rising by 3.5% according to the Medicare Economic Index.
So, while MA plans receive an increase beyond the expected healthcare inflation rate, Congress not only failed to provide a physician payment update but allowed a new round of cuts at the end of the lame duck. It's unbelievable they're giving insurance companies that had record profits an increase while at the same time cutting payment to physician practices that are struggling to survive. This contrast highlights the urgent need for Congress to prioritize linking payment to physician practices to the cost of providing care. Otherwise, with or without MA plans, patient access will suffer if physicians close their practices. A new Congress is meeting — it’s time for a new approach to physician payment reform.”
Source: Bruce A. Scott, MD, President, American Medical Association
01/01/2025
RESPONSES/COMMENTS (MEDICARE ADVANTAGE IN THE NEWS)
RE: NY Medicare Advantage Insurer and CEO Will Pay Up to $100M
From: Paul Kesselman, DPM
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...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
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
12/31/2024
MEDICARE ADVANTAGE IN THE NEWS
NY Medicare Advantage Insurer and CEO Will Pay Up to $100M
A western New York health insurance provider for seniors and the CEO of its medical analytics arm have agreed to pay a total of up to $100 million to settle Justice Department allegations of fraudulent billing for health conditions that were exaggerated or didn't exist. It's one of the first cases to accuse a data mining firm of helping a health plan overcharge.
Independent Health Association of Buffalo, which operates two Medicare Advantage plans, will pay up to $98 million. Betsy Gaffney, CEO of medical records review company DxID, will pay $2 million, according to the settlement agreement. Neither admitted wrongdoing.
Source: Fred Schulte, KFF Health News [12/24/24]
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
11/14/2024
QUERIES (MEDICARE ADVANTAGE)
RE: Requirement to Accept Medicare Advantage Plans
From: Eric D. Trattner, DPM
If we participate in commercial plans such as Aetna and Humana are we required to accept their Advantage plans?
Does anyone have experience dropping Advantage plans in their practice?
Eric D. Trattner, DPM, Twinsburg, OH
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
10/30/2024
RESPONSES/COMMENTS (MEDICARE ADVANTAGE PLANS)
RE: Time to Unionize
From: David Shaffer, DPM
Have you ever been told by a Medicare Advantage plan that their panel is full? It's time for all podiatrists to unionize. One does not have to look far to see that we are being discriminated against, by not allowing those that want to participate in the Medicare Advantage plans. How do you think Medicare Advantage plans are funded? The Center for Medicare and Medicaid Services pays private plans on a per capita basis. In 2023, CMS paid the Medicare Advantage plans 454 billion dollars, amounting to more than 1/2 of Medicare spending last year.
If the federal government is utilizing taxpayers’ money to subsidize Medicare Advantage plans, then it should allow all licensed doctors (including podiatrists) to be allowed to treat Medicare Advantage patients without being told that the panel is filled or the certification status is questionable. The use of federally funded money (taxpayer funded) dictates that anyone who wishes to participate should be able to do so!
With unionization comes strength, and allows legal representation in a class action lawsuit against all the Medicare Advantage plans that prevents any podiatrist the ability to get on these plans using taxpayers’ money… thus, preventing future earnings potential. Now is the time to step up and take action. Unionize now and stop the HMOs from taking advantage of you!
David Shaffer, DPM, Great Neck, 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
