US sues Kaiser Permanente over alleged Medicare fraud

[Omaha Steve]

Source: AP

SAN FRANCISCO (AP) — The federal government has sued Kaiser Permanente, alleging the health care giant committed Medicare fraud and pressured doctors to list incorrect diagnoses on medical records in order to receive higher reimbursements, officials said Friday.

The U.S. Department of Justice lawsuit, filed Thursday in federal court in San Francisco, consolidates allegations made in six whistleblower complaints.

Kaiser, based in Oakland, California, is a consortium of entities that together form one of the largest nonprofit health care plans in the U.S. with more than 12 million members and dozens of medical centers.

The lawsuit said Kaiser entities gamed the Medicare Advantage Plan system, also known as the Medicare Part C program, which gives beneficiaries the option of enrolling in managed care insurance plans, according to a statement from the U.S. Department of Justice.

Read more: https://apnews.com/article/business-health-medicare-566111a018e5e8f3d0224180050cbf0a

[bucolic_frolic]

1. Imagine what they do to the uninsured

[C Moon]

14. My wife got the COVID vaccine through them (as a non-member).

Then a couple months later, we got a bill from our insurance, that Kaiser is claiming the second dose was an anesthesia treatment.
:O
Okay, she showed up for a shot of anesthesia, then went home.

[Grokenstein]

2. Good. I wonder if KP's still pushing Jenny Craig on patients.

Last time I went, my GP was very desperate to get me to sign on; I have to presume there were commissions for every sucker hooked.

But I had already seen Jenny Craig ads on late-night teevee promising "guaranteed" results--complete with an asterisk leading to a blurb of fine print negating the very same promise--and a mass-produced one-size-fits-all solution to a problem that is actually rather complex was already suspicious. You know how this game is played: they set you up to fail, and when it happens they say you didn't try hard enough. Still, a polite "hard pass" earned me a cold shoulder on the problem I came to see the doctor about in the first place.

Kaiser's specialists were great, but four out of five of the general practitioners I saw were primarily interested in pushing pills and plans. Gotta pay for that annual multimillion-dollar ad campaign to convince everyone that the HMO is "in the hands of doctors." (Wow, linked article is from 2002! They've been in trouble before.)

[PatSeg]

3. Reminds me of going to Firestone to buy tires

and they try to sell you shocks and brakes. With retailers, it is annoying, but with medical professionals, it is very disturbing and unethical.

[Prof. Toru Tanaka]

13. To me, Midas is the worst

when it comes to high-pressure "you need _____" to fatten the ticket. If I need muffler service, I'll go to Meineke or elsewhere.

I'm waiting for the day when I see my health insurance provider getting their hand caught in the cookie jar like this.

[PatSeg]

21. Employees at such places are trained

to increase the customer average sale with add-ons, many of them unnecessary. Many years ago I took my Volkswagen Beetle to Firestone for a new set of tires. The mechanic started to rattle off a list of mechanical problems and when he got to "your automatic transmission fluid is leaking" I cracked up. "Seriously? It is a stick shift!" Realizing his mistake, even he started to laugh and just sold me the tires I'd asked for.

Unfortunately, I've had health care providers do similar things with additional and often redundant tests and procedures.

[Prof. Toru Tanaka]

22. That's pretty good!

I guess there was nothing else to do but laugh at that "busted" moment. Like Mr. Lee on that old Calgon commercial when his wife exposed the "Ancient Chinese Secret".

[PatSeg]

24. It was such a rare and priceless moment

One I never forgot and I'm sure he hated having to do this cheesy upsell with every customer.

[oasis]

4. Good. Bring the hammer down on those damn crooks.

[DENVERPOPS]

7. If you want some real horror stories

about Kaiser just talk to any EMT who has ever dealt with a Kaiser Patient or Kaiser.

[Demovictory9]

10. Kaiser sux

[Dream Girl]

12. I've been a member for 25 years, had my son there and went through two major illneses

Nothing but great quality care and professionalism. My doctors are respectful, proactive and competent. If I need a test or procedure, I’ve never felt they balked or counted pennies. I wish people wouldn’t post about things they no nothing about!

[C Moon]

15. We were with them for a couple of decades...

and finally decided to get out. My wife had to go to a podiatrist outside of Kaiser to good treatment for plantar, she's fine now, but the Kaiser podiatrist was awful.

I think they are overburdened (in So. CA, anyway), and it's tough to find a good doctor. I had one of the worst experiences with a sit-in doctor while mine was out for a new baby (I liked the doctor I found, BTW), but the sit-in doctor was terrible! She did not want to be there, and talked down to me the whole time. I should have just walked out.

I do miss the easiness of procedures, blood tests, vaccines, etc. But I don't miss the care.

[Dream Girl]

16. I'm in NorCal, so maybe that's the difference? They've also changed a lot. Very procative

And the doctors work as a team.

[C Moon]

19. Thumbs up!

[DENVERPOPS]

20. I am glad

that you have had good experiences with Kaiser.

I will stop there.

[CountAllVotes]

25. Good tolerance!

I hate hate hate these SOBs!

They did a real number on my late father.

Dad died and where the hell was Kaiser?

Dad was laying in a rehab. center as a vegetable while they were no where to be found due to a "nursing strike".

Uh huh.

FUCKERS.

[DENVERPOPS]

26. Thank You CAV

I appreciate it...............

[CountAllVotes]

27. Back at ya!

[msfiddlestix]

28. I've have an excellent provider, and specialists have treated me very well

this round of being with kaiser is roughly 5 years. I have a fantastic doctor and he doesn't ever try and pull this crap on me.

Live in the North Bay, if that makes a difference.

[Casady1]

5. Calling Ric Scott

This is your gig.

[nitpicker]

6. Link to the DoJ PR

https://www.justice.gov/usao-ndca/pr/government-intervenes-false-claims-act-lawsuits-against-kaiser-permanente-affiliates

(snip)
SAN FRANCISCO – The United States has intervened in six complaints alleging that members of the Kaiser Permanente consortium violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements.

The Kaiser Permanente consortium members (collectively Kaiser) are Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan of Colorado, The Permanente Medical Group Inc., Southern California Permanente Medical Group Inc. and Colorado Permanente Medical Group P.C. Kaiser is headquartered in Oakland, California.
(snip)

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the diagnoses of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with more severe diagnoses will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.

Medicare requires that, for outpatient medical encounters, MA Plans submit diagnoses to CMS only for conditions that required or affected patient care, treatment or management during an in-person encounter in the service year. In order to increase its Medicare reimbursements, Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.
(snip)

[erronis]

11. Thanks for that link. I used to be a KP patient - it was fine for me but I didn't have real probs.

[dalton99a]

8. SIX whistleblower complaints

The lawsuit contends that Kaiser “pressured its physicians to create addenda to medical records,” often months or more than a year after an initial consultation with an enrollee, because more severe diagnoses for beneficiaries generally result in larger payments to the plan.

[AllaN01Bear]

9. here is the real medicare fraud and medicare queens .

[Tikki]

17. I wish there would be a class action, because I would be first in line.

Too much of a story to tell here, but.....


Tikki

[BadgerKid]

18. Wonder if Medicare medical reimbursement rates

Make it a net loss. I’ve heard that’s the case for Medicare dental.

[disndat]

23. How about the DOJ calling

off investigations of nursing homes in NY, Pa, and Michigan covid deaths?