Read about it here: Whistleblowers accuse health insurers of scamming Medicare to make billions
Kaiser and others accused of Medicare Fraud!
- Thread starter Todd King
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- medicare medicare fraud
An insurance company would commit fraud against the government? Say it ain't so, Joe!
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I think these are [most] interesting parts:
"these models became central to the growing Medicare Advantage industry. Money hinged on the illnesses that plans documented for their members. Traditional Medicare pays doctors and hospitals directly for each test or service. In Medicare Advantage, health plans get a fixed payment from the government for each member they take on. The program will spend on average about $14,000 per enrollee this year. Through a process called risk adjustment, added diagnoses typically bump payments by $1,000 to $5,000, sometimes even $10,000, according to MedPAC. It’s meant to compensate insurers for taking on sicker patients and discourage them from cherry-picking healthy people."
....
"Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them."
....
"Her whistleblower suit and the Justice Department complaint that followed describe a growing pressure within the company to engineer higher risk scores for greater payments."
....
" the Department of Justice intervened in six other cases against Kaiser Permanente filed by separate whistleblowers alleging that it defrauded Medicare through inflated risk codes. "
"these models became central to the growing Medicare Advantage industry. Money hinged on the illnesses that plans documented for their members. Traditional Medicare pays doctors and hospitals directly for each test or service. In Medicare Advantage, health plans get a fixed payment from the government for each member they take on. The program will spend on average about $14,000 per enrollee this year. Through a process called risk adjustment, added diagnoses typically bump payments by $1,000 to $5,000, sometimes even $10,000, according to MedPAC. It’s meant to compensate insurers for taking on sicker patients and discourage them from cherry-picking healthy people."
....
"Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them."
....
"Her whistleblower suit and the Justice Department complaint that followed describe a growing pressure within the company to engineer higher risk scores for greater payments."
....
" the Department of Justice intervened in six other cases against Kaiser Permanente filed by separate whistleblowers alleging that it defrauded Medicare through inflated risk codes. "
In truth, there is very little oversight and accountability in the health care field. Managed care is more about carriers finding ways to deny/short claims to the provider and shifting as much as possible to the patient.
Many patients (regardless of age) have no clue how their plan works . . . just ask the providers that see patients on a regular basis. If the claim is denied or shorted, more often than not, the patient pays the bill and chalks it up to "that's the way it always is". Claims are rarely challenged.
We find that, across HealthCare.gov issuers with complete data, about 17% of in-network claims were denied in 2019, and about 14% of in-network claims were denied by issuers in 2018, with rates for specific issuers varying significantly around these averages.
Of all denials with reasons reported for 2019, about 18% were denied because the claim was for an excluded service; about 9% were denied due to prior authorization or lack of referral, and less than 1% were denied based on medical necessity. The remaining plan-reported denials (72%) were denied for other reasons.
https://www.kff.org/private-insuran...denials-and-appeals-in-aca-marketplace-plans/
In 2019, about 40% of denials that enrollees appealed internally to their health plans were overturned. The overturn rate of appealed claims denials varied by issuer. Among 119 issuers whose appeals outcomes data were not suppressed, the overturn rate ranged from less than 15 percent to over 90 percent.
https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plan
The following is a few years old but I see nothing that indicates improvement.
A growing number of U.S. seniors are choosing Medicare Advantage, the popular private insurance alternative to traditional coverage. But a new report by federal investigators finds that Advantage plans have a pattern of inappropriately denying patient claims.
The good news is that those denials are frequently overturned if people bother to appeal.
The report found "widespread and persistent problems related to denials of care and payment in Medicare Advantage" plans, which usually are managed-care HMO or PPO plans.
The review found that 24 percent of denied Medicare Part A (hospitalization) claims were overturned on appeal, and 51 percent of Part B (outpatient services) denials were overturned. A larger share of enrollees in traditional Medicare (2.6 percent) appealed claim denials - still a relatively small share.
Column: U.S. probe shines light on Medicare Advantage claims denials
This linked article views claim denials from the provider perspective.
https://www.drcatalyst.com/medical-claim-denials-appeals-statistics-that-you-want-know
Medicare Advantage Plans Overturn 75% of Their Own Claim Denials
https://revcycleintelligence.com/ne...-plans-overturn-75-of-their-own-claim-denials
To me, it is suspicious to see the dearth of RECENT information on this topic. Either the industry has substantially improved the claims adjudication process in the last few years, consumers are becoming more complacent, or the industry is more judicious in suppressing "bad" reviews . . .
Many patients (regardless of age) have no clue how their plan works . . . just ask the providers that see patients on a regular basis. If the claim is denied or shorted, more often than not, the patient pays the bill and chalks it up to "that's the way it always is". Claims are rarely challenged.
We find that, across HealthCare.gov issuers with complete data, about 17% of in-network claims were denied in 2019, and about 14% of in-network claims were denied by issuers in 2018, with rates for specific issuers varying significantly around these averages.
Of all denials with reasons reported for 2019, about 18% were denied because the claim was for an excluded service; about 9% were denied due to prior authorization or lack of referral, and less than 1% were denied based on medical necessity. The remaining plan-reported denials (72%) were denied for other reasons.
https://www.kff.org/private-insuran...denials-and-appeals-in-aca-marketplace-plans/
In 2019, about 40% of denials that enrollees appealed internally to their health plans were overturned. The overturn rate of appealed claims denials varied by issuer. Among 119 issuers whose appeals outcomes data were not suppressed, the overturn rate ranged from less than 15 percent to over 90 percent.
https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plan
The following is a few years old but I see nothing that indicates improvement.
A growing number of U.S. seniors are choosing Medicare Advantage, the popular private insurance alternative to traditional coverage. But a new report by federal investigators finds that Advantage plans have a pattern of inappropriately denying patient claims.
The good news is that those denials are frequently overturned if people bother to appeal.
The report found "widespread and persistent problems related to denials of care and payment in Medicare Advantage" plans, which usually are managed-care HMO or PPO plans.
The review found that 24 percent of denied Medicare Part A (hospitalization) claims were overturned on appeal, and 51 percent of Part B (outpatient services) denials were overturned. A larger share of enrollees in traditional Medicare (2.6 percent) appealed claim denials - still a relatively small share.
Column: U.S. probe shines light on Medicare Advantage claims denials
This linked article views claim denials from the provider perspective.
https://www.drcatalyst.com/medical-claim-denials-appeals-statistics-that-you-want-know
Medicare Advantage Plans Overturn 75% of Their Own Claim Denials
https://revcycleintelligence.com/ne...-plans-overturn-75-of-their-own-claim-denials
To me, it is suspicious to see the dearth of RECENT information on this topic. Either the industry has substantially improved the claims adjudication process in the last few years, consumers are becoming more complacent, or the industry is more judicious in suppressing "bad" reviews . . .
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