Government lets health plans that ripped off Medicare keep the money

[marmar]

Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018. Exactly how much is not clear because audits as far back as 2011 have yet to be completed. ...........(more)

https://www.salon.com/2023/02/01/government-lets-health-plans-that-ripped-off-medicare-keep-the-money_partner/

[Ray Bruns]

1. But if you owed $147 to the IRS, the SWAT team would be busting down your door.

[Backseat Driver]

15. Nah, that's a bit facetious...

but you might get a single notice about a potential default in the mail...and not even necessarily "certified/RRR." I've had state and regional tax notices go undelivered for weeks despite a notice that the envelope contains a printed phrase about timeliness of delivery. Our rental complex accepts mailed pieces for a resident (if missing, it's on you to check) and passes out only a single mailbox key per unit residence and is serviced on an alternate route by "extras." If you don't see it or fail to reply to it or go on a repayment plan soonest, they'll be happy to just continue to let it ride. Higher penalties and interest will keep accruing to their benefit. Tax, school loan, and postal CSR's, including the local postmaster, are not reliable agents of government process--nor is the uniformed person who delivers the mail or the civilian resident/property manager who accepts or picks up one's mail. And it's all soooooo accidental.

[CrispyQ]

2. This is the kind of shit that makes people hate & distrust government.

Do any sick people get a reprieve from their fucking medical bills? Oh, hell no!

Socialism for the rich, capitalism for the rest of us.

[Backseat Driver]

10. Be sure to get ALS or ESRD for special government cost saving benefits at any age.

The costs are still astronomical but, yes, some sick do qualify for a partial reprieve, but family caretakers also have major financial trauma without major assistance for circumstances that could last many years. Life lesson hint: If you are not already independently uber-wealthy; don't be blinded by love; never marry an "only child" unless there's irrevocable proof of "protective" familial uber-wealth and/or your or your beloved's parent(s) are already dead and buried.

[BSdetect]

3. So many questions regarding this. Why was the problem undetected? WTF

So no ethics at health care companies with overpayments not returned or even brought to the attention of the government?

[CrispyQ]

12. Who just pays the bills without checking if the charges are within guidelines?

The insurance companies sure don't! They have pages of codes to determine what gets paid. The govt doesn't do the same?

[Backseat Driver]

13. I've wondered the same. I came to the conclusion that oversight is lacking. Do note that

DOJ/LEO investigations take time. Ever see how much TPTB allow to occur before fraud is litigated; don't forget appeals from deep pocket corporate defendents. Lots of costs and wasted resource legal paid time. Otherwise, folks are not knowledgeable about even basic anatomy and physiology and that type of expertise, watching over the pediatric or geriatric patient's well-being and financial status, costs plenty too.

[Wounded Bear]

4. How much of that money went to DeSantis's election campaign?

Just askin'

[aocommunalpunch]

5. Keep the corruption free flowin'.

That'll bring folks to the polls.

[in2herbs]

6. Just like all of the $$$$ fraud in the PPP has been forgiven. Who makes the decision to

allow this? Shouldn't Congress have to vote on this? After all it affects the budget.

[yellowdogintexas]

7. when I audited medical rhecords for Medicare Part B

I was working on claims from 3 to 5 years back. We requested overpayments about 45 days after the audit was completed. These were based on claims from only one physician group (teaching/faculty docs) at a time covering a specific period. Each hospital and time period was handled separately. I spent a week out of town reading records and compiling reports, then another 30 days getting the data pulled together and writing the report. (this was in the 1970s and we did not have much computer help)

The overpayments were much smaller though. We were dealing with teaching physicians billing inpatient services which were only documented in the record by the residents; Essentially, resident services to patients were reimbursed directly to the facility via Part A, because residents were considered employees of the facility. Attending/teaching physicians who billed for those services had to sign off in the record to show they personally rendered the services

The strange overlap of reimbursement in the teaching facility setting has been eliminated by some changes in Part A billing procedures. If I had stayed at that job a year longer my position would have been eliminated anyway.

I can understand holding off taking action until the audit is completed. We were understaffed for what we needed to do and I doubt that has changed much. I do not necessarily think they should do that, I just understand why.

The wheels turn slowly and always have.

[Backseat Driver]

14. Late in my community college classes that made me eligible to take the test for state licensing

(at the time a $200 test) as an ART, it slipped out I would likely need to self-pay for a personal liability insurance policy while following my employer guidelines and/or verbally delivered "new policy" for, perhaps, a fraudulent pattern of coding. So, keep working under escalating self-paid premiums for insurance (just like the physicians' policies) and pray one is never specifically named, whistleblowing, blackmail or taking bribes, seemed to be the certain options open to coders who had either idealistic, ethical habits or who quickly learned the corrupt "skills" OJT to stay working.

Were you perhaps bonded or have a self-paid personal liability policy in that job in which you delivered a final audit report? Was it considered a forensic audit? We did learn what symptom terms, lab results, additional diagnoses could constitute elevating a DRG, if documented and entered into the automated information sent on into EOB billing/reimbursement software. Also a bit about utilization reviews, but I also pretty much missed the necessary bridgework and delays in implementation between ICD-9-CM and ICD-10. By then I was working as a lowly non-hospital transcriptionist having left the state license behind.

[yellowdogintexas]

16. it was a documentation audit only. If the doc I was working on did not sign

the medical records for the claims we reviewed we could request an overpayment
I was employed at the time by the Medicare Part B Carrier for the state of Tennessee. Fortunately I did not need to worry about ICD9 or CPT codes or DRG. I think DRG came along about 2 years later and was part of the reason my job was phased out.

I did not need to be bonded as I represented the insurance carrier under the full authority of the Social Security Administration.

My job duties moved from the physican audits to working out the very beginning phases of electronic billing. That was cool.

Not a forensic audit. In my years of processing medical claims and other related jobs, I learned a LOT about medical terms, drugs, procedures and other things. I can also read a policy and figure out what is covered, not covered and whether or not it is a rip off.

I loved working in medical claims

[angrychair]

8. Police beat a man to death

For a traffic infraction.

Large corporations overtly steal hundreds of millions, billions of dollars.and...nothing.

This is why it matters.

[dalton99a]

9. Kick

[CrispyQ]

11. This pisses me off that Kaiser was a very big part of this

but as insurance companies go, I'm really happy with my Kaiser Medicare Advantage coverage.

on edit: I'm not trying to push Medicare Advantage. I know there are lot of arguments against it, but I live in a Kaiser rich environment & have been very happy with their care & coverage.

[Hermit-The-Prog]

17. There are no consequences. There is no law for oligarchs.