The Medicare Advantage trap: What they don't tell you

[Silent Type]

26. First off, Clinton signed legislation for Part C. And it is not true that Medicare pays for anything a doctor

says you need. They have detailed coverage policie for all kinds of procedure, tests, etc.


Original Medicare pretty much follows a "pay and chase" scheme. They'll pay most claims upon submission -- but do deny some on frontend -- but periodically audit doctors who show higher utilization rates than the typical physician in that specialty. If the records don't support the care billed, they recoup the money, but from the doctors. If the doc knew what he or his billing service was doing, they might be charged with fraud.

This is why you see Medicare pursuing a doctor years after the service was billed for $21 million in services that were never performed. The "pay and chase" lets a lot of improper claims through.

Advantage plans, are more likely to deny suspected improper claims up front than through audits years later. Over 80% of initial denials by MA are overturned when the doctor provides additional information like, "Oh, chit, we forgot to mention that the patient developed pneumonia just before the typical discharge date, please allow the additional days."

Many of the denials are partial denials, Doctor asked for 14 days of therapy, but we are only approving 10 days at this point and will reconsider additional days if patient is making progress. Original Medicare's payment policy might also deny claims after the typical, standard of care, period. If you read, UHC, Aetna, Cigna, etc., coverage policies, they mostly follow CMS/Medicare policies word for word. Whether those policies are applied correctly is another matter, but that's true under original Medicare too.
Believe it or not, doctors do cheat.

I've seen cases where a doctor might order an expensive test 1 time for every 100 patients when the patient has to be referred to another facility for the test (facility bills and profits in that case). Then, when the doc buys similar testing equipment for their office, thus being able to profit from it personally, the utilization rate jumps 400%. What that tells me is that the test wasn't needed that often, until the doc could profit off it.

I've asked doctors who billed a high paying code -- when they only performed a lower paying code -- why they chose the higher paying code? The answer from a supposedly intelligent person was, "Because I looked down the list of codes and the code I billed paid the most."

Admittedly, the rules are confusing, but that’s true under original Medicare too.

If you don't believe providers cheat Medicare, read this from the HHS OIG.

https://oig.hhs.gov/fraud/enforcement/