Let's Focus On The Health Insurance Industry

And We Must Ask Ourselves, Do We Want To Do Business With These Folks?

Snidely At The Railroad Tracks

Last week a patient transitioning to Medicare informed me that their Aetna Medicare Advantage PPO plan was assigning a Primary Care Physician as part of the contract. Also last week, at a physician Medical Society strategy meeting, a doctor informed some that there exists significant payment incentives in the new Medicare plans. This led me to put two plus two together. Conclusion: there is a scheme afoot.

And What A Scheme It Is

Years ago as unhappy patients left the local corporate models, I learned that a main reason for this was they couldn’t get an office visit. They couldn’t even call to request an appointment or ask a question. IF they wanted any service, they had to first sign into the practice Electronic Health Record’’ portal. I speculated that the company policy was likely so in order to start a record of “chronic care” management. From my research today this is exactly the case.

Let’s Review The Birth And Transformation Of The Chronic Care Management Code for Medicare Beneficiaries.

In 2015, the Chronic Care Management (CCM) code—CPT 99490 was introduced by CMS to Medicare providers. CMS will tell you they did this to improve patient care, encourage coordination of services and promote “team management”.

The real truth is CMS was threatened with losing all the primary care physicians’ participation. This was due to inadequate Relative Value Unit reimbursement and ever rising care costs from unrelenting patient services demand. What was happening was primary care doctors were recognizing the added bureaucracy of the coded payment RVU scheme was anchored in the past and unable to accommodate the improved technology provided by Electronic Health Records and modern communications.

Like our practice, doctors realized they could provide continuous patient care contact in and out of the office. In order to invest in providing this model, the savvy entrepreneurs had to reprice their care model and we weren’t going to wait around for the 16 member CMS committee to pay for what both doctors and patients wanted. The result was a monthly practice fee with a large list of services provided within the membership. CMS’s revised payment schemes was an attempt to stop this trend.

Physician lobbies articulated the lack of reimbursement problem to our government and insurance payers. They convinced CMS that the primary care doctors should be incentivized to provide annual physical exams and functional appraisals of our Medicare aged patients. This led to the first “give me” new code of the annual physical exams. This subsidy was intended specifically for primary care physicians.

Prior to the new code, Medicare didn’t cover annual exams. Doctors and patients had to “make up” a reason to come in for such a service. After the code, the patients were herded into the office twice annually to satisfy the government care requirements. First, a nurse or office staff person scheduled the patient to come in for a host of inquiries. Basically, occupational and physical therapy assessments and mood and memory screening was done. Then the patient was scheduled with the doctor to review this data and arrange a care plan based upon the results.

This new “Annual Wellness” program opened the Pandora’s box and led to the added chronic care management scheme. Having given in on annual health exams, now the primary care doctor lobby was able to get a sympathetic ear to help cover all the staff time and overhead consumed in the primary care office. Again, IF the physician was willing to document 20 minutes of care on any 30 day billing cycle, Uncle Sam would stroke a check for that service. Following that, the system will pay additional fees for going past an hour of chronic care management. Today while researching the history and facts around the new “assigned” PPO doctor letter, I have now confirmed that hospitals also get to tag on facility fees INDEPENDENT of whether a physician oversight code applies. It starts at 29 bucks a month.

So Here Is A Table Showing How Medicare Chronic Care Codes Can Be Applied.

The G codes are the facility payments. It turns out if properly “maximized” this scheme can bring in an extra $5700 dollars in revenue to the providers. It can’t come as a surprise that once again Hospital systems win big in this scheme. Also numerous “billing and data documentation” middleman businesses have sprung up around what was supposed to be physician care payment. My further inquiries also confirm that the Insurance Companies themselves are trolling for these dollars- hence the “assigned physician clause”.

In The News Is Lots Of Health Insurance and Medicare Fraud

If you are paying attention at all, it is clear that Obamacare hasn’t improved our individual nor national health care costs on iota. It is also clear the foxes are in the henhouse. Unfortunately no matter how much we cluck, nothing positive changes. Let me give you some examples on the fraud front.

1. US Department Of Justice accuses Medicare Insurers and brokers of fraud.

2. South Texas Couple Pleads Guilty in $14 Million Medicare Fraud Scheme

3. Dafud Iza, an executive vice president of a Florida insurance brokerage firm, pleaded guilty to a scheme that submitted fraudulent applications to enroll consumers in Affordable Care Act insurance plans.

4. The DOJ's recent lawsuit against major insurers and brokers marks a significant step in scrutinizing the Medicare Advantage program.

5. UnitedHealth Group under scrutiny for upcoding. They are under investigation by the Department of Justice (DOJ) for allegedly inflating patient diagnoses to secure higher Medicare payments—a practice known as upcoding. This ties to the growing use of assigned doctors to Advantage plans.

6. Independent Health Settles Upcoding Allegations for $100 Million

7. RAND Study Reveals Widespread Hospital Upcoding- Most Favored Nation Status has its benefits.

8. Legislative Efforts to Curb Upcoding in Medicare Advantage are being pursued. It’s called the “no upcode act”.

So How Can Having An Assigned PCP Be Used To Increase Payment to The Insurance Company?

Potentially, Medicare Advantage (MA) insurers like Aetna use PCP assignment schemes to game CMS quality metrics and billing patterns without the patient’s awareness or informed consent. Yes, assigning PCPs without true patient-provider relationships can be a mechanism for fraud, especially when used to:

• Inflate care coordination metrics

• Bill for preventive services not actually delivered

• Boost risk adjustment scores without clinical justification

These actions distort Medicare reimbursements, funnel public funds to insurers, and mislead regulators—all under the guise of patient care coordination.

There are “quality care” excuses that result in payments from Medicare provided documentation is done. THIS FOLKS, IS WHY MEDICARE PATIENTS HAVE INSURANCE NURSES/NAVIGATORS AND ASSIGNED PRIMARY PROVIDERS ATTACHED TO THEIR INSURANCE CARD.

Do We Keep Buying Health Insurance and Medigap Insurance Out of Mass Formation?

The fact that no one is willing to stop writing checks despite the ever rising evidence of abuse, harassment and fraud describes a collective psychological state where a population becomes highly susceptible to groupthink and authoritarian control during times of fear, social isolation, and free-floating anxiety.

What is it going to take to put a stop to this ongoing abuse train? If people just stopped writing checks to Health Insurance Companies they would dry up and go away. Why can’t we take this stand and get this to stop? The corollary is why do doctors keep in the henhouse as well?