Benjamin Schwartz, MD, MBA’s Post

I’ve now seen several articles on this topic, but this one still showcases one of the more egregious efforts to extract dollars from CMS by Medicare Advantage plans. But please, let’s continue to cut healthcare costs by cutting physician reimbursement. TL;DR The Wall Street Journal's investigation into Medicare Advantage reveals widespread issues with how private insurers are diagnosing patients to increase payments from the government. The analysis shows that insurers often add or alter diagnoses, such as diagnosing diabetic cataracts in patients who do not have diabetes, leading to substantial additional taxpayer costs. From 2018 to 2021, Medicare Advantage insurers received millions in extra payments by inflating the severity of patients' conditions, despite many diagnoses being incorrect or unsupported by subsequent care. This practice has led to billions in unnecessary costs, undermining the original goal of Medicare Advantage to provide more cost-effective care. The findings highlight significant discrepancies between insurer-driven diagnoses and actual patient care, prompting concerns about the system's integrity and efficiency.

Be aware that sometimes the practice of medicine and insurance is about profits as a priority, not necessarily quality health care. 💼💊 It's crucial to recognize that in the healthcare sector, especially with companies like UnitedHealth and Optum Care, profit motives can sometimes overshadow the quality of care.📧📄 Their recent strategy regarding Medicare Advantage highlights this tension, as new insights reveal efforts to reshape healthcare delivery.🤔🔍 This could significantly impact both patients and providers, raising important questions about prioritizing quality over profit in healthcare services. What are your thoughts on this balance? 🚀🩺 Share your thoughts and let's discuss how this could impact patients and providers alike! 🗣️👥 #MedicareAdvantage #OptumCare #ProfitOverCare? #FutureOfHealthcare #PatientImpact https://hubs.la/Q02TZbNT0

Be aware that sometimes the practice of medicine and insurance is about profits as a priority, not necessarily quality health care. 💼💊 It's crucial to recognize that in the healthcare sector, especially with companies like UnitedHealth and Optum Care, profit motives can sometimes overshadow the quality of care.📧📄 Their recent strategy regarding Medicare Advantage highlights this tension, as new insights reveal efforts to reshape healthcare delivery.🤔🔍 This could significantly impact both patients and providers, raising important questions about prioritizing quality over profit in healthcare services. What are your thoughts on this balance? 🚀🩺 Share your thoughts and let's discuss how this could impact patients and providers alike! 🗣️👥 #MedicareAdvantage #OptumCare #ProfitOverCare? #FutureOfHealthcare #PatientImpact https://hubs.la/Q02TZ8Cw0

🔍 Unraveling the Mystery of Medicare Part B 🔍 Medicare Part B is an essential component of the government's healthcare coverage for individuals aged 65 and older. Here's a breakdown of what Medicare Part B entails: 🔹 **Medically Necessary Services**: Part B covers services or supplies that are deemed medically necessary to diagnose or treat a medical condition. 🔹 **Preventive Services**: It also encompasses preventive services to help maintain your health and catch potential issues early on. 🔹 **Outpatient Care**: Part B specifically caters to outpatient care, including doctor's visits, lab tests, and durable medical equipment. 🔹 **Types of Providers**: You can receive Part B services from doctors, specialists, and other healthcare providers who accept Medicare assignment. 🟢 **Beneficiary Responsibility**: While Part B offers comprehensive coverage, beneficiaries are required to pay a monthly premium and are subject to deductibles and co-payments. 🟢 **Enrollment Considerations**: Keep in mind that there are specific enrollment periods for Medicare Part B, so staying informed and timely with your decisions is crucial. 🟢 **Supplemental Coverage**: Some individuals opt for supplemental insurance to cover the costs that Medicare Part B doesn't, providing additional peace of mind. In essence, Medicare Part B plays a vital role in ensuring that individuals have access to necessary healthcare services, promoting overall well-being and quality of life. Stay informed, make informed decisions, and take charge of your healthcare journey! ✨ #MedicarePartB #HealthcareCoverage #StayInformed 🌟

Optimizing Risk-Adjustment: A Solution to Healthcare Inefficiencies and Waste When applied correctly, the risk-adjustment system is a transformative solution to the inefficiencies in our healthcare system, addressing over $1 trillion in waste. By accurately adjusting payments based on patient health status, providers are incentivized to focus on prevention and early-stage disease management rather than unnecessary spending on end-stage care. This model aligns financial incentives with proactive care, enabling investment in preventive measures and early interventions. This approach improves patient outcomes and reduces long-term costs by preventing untreated conditions from escalating into severe complications. Funds from accurate risk adjustment allow providers to offer specialized services and community health programs for complex and underserved populations. These investments address social determinants of health and ensure comprehensive care, mitigating disparities in healthcare access and outcomes. The system promotes proactive healthcare, prioritizing early identification and treatment. Rewarding accurate diagnosis and disease management shifts focus to long-term health outcomes rather than short-term financial gains, leading to better patient health and a sustainable system. However, instances of misuse, as highlighted in a recent Wall Street Journal article, show some insurers exploiting the system by adding questionable diagnoses to inflate payments, leading to excess costs. This misuse undermines integrity and diverts funds from genuine patient care. False diagnoses and lack of treatment for serious conditions waste taxpayer money and erode trust. Patients and doctors are often unaware of these diagnoses, meaning the supposed benefits of risk adjustment are not realized in actual care. It's crucial to recognize that reliance on home visits and chart reviews, even when aided by AI, can lead to inaccurate coding. Insurer incentives to maximize payments can sometimes overshadow the primary goal of promoting patient well-being. Therefore, robust mechanisms are essential to ensure the ethical use of the risk-adjustment system. The key to a successful risk-adjustment system is to provide physicians with more oversight and control. This ensures that the system is not just effective, but also patient-centric, with patients and physicians at its core. https://lnkd.in/gYcKhw8x

"When Congress conceived of the Medicare Advantage program decades ago, the hope was that insurers would make Medicare more efficient. In traditional Medicare, doctors and hospitals get paid for each service they provide, an incentive to provide more. The idea behind Medicare Advantage was to pay private insurers a lump sum to cover all services, giving them an incentive to keep patients healthier. To protect insurers from the risk of winding up with sicker-than-average patients, the government allowed bigger payments for certain serious health conditions. Partly because of that, Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report by the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer."

According to The Wall Street Journal, Insurers have raked in $50 billion from Medicare for diseases that were NEVER treated by doctors! The jaw-dropping exposé has uncovered a scandal that should outrage every taxpayer and healthcare professional. This isn't just a glitch in the system - it's a blatant exploitation of our most vulnerable citizens and a gross misuse of taxpayer money. I recommend reading the article here https://lnkd.in/ew8AYXmM - Private insurers in the Medicare Advantage program fabricated hundreds of thousands of diagnoses. - These "diagnoses" led to billions in extra payments, all while patients remained untreated and uninformed. - Insurers manipulated records using chart reviews and home visits, sometimes with the aid of artificial intelligence, to concoct these false diagnoses. The Impact on Patients is severe. Imagine being told you have a serious illness like HIV or diabetic cataracts when you don't. It's not just a paperwork error; it's a life-altering lie. Patients, many of whom are elderly and disabled, were left in the dark, believing they had conditions that required no treatment. To build a healthcare system that genuinely benefits patients and respects taxpayer contributions, collaboration is essential. Stakeholders across the industry can join forces to create a trustworthy and efficient healthcare ecosystem.

The emails from UnitedHealth Group managers were filled with exclamation marks and pleasantries about the weather. But the underlying message to doctors in late 2020 was persistent and urgent: Hit your targets to see more patients. We need to bring in more money. At the time, deaths from Covid-19 were surging, and no vaccine was available. But inside a UnitedHealth practice, the “#1 PRIORITY” became documenting older patients’ chronic illnesses to generate more revenue from the federal government, the emails show. UnitedHealth shared with doctors in the practice a dashboard comparing the percentage of chronic diseases they found among their Medicare Advantage patients to other practices within the company. Those who completed the most appointments with older patients got a “SHOUT OUT!!” in the messages and were eligible for up to $10,000 in bonuses. “We can do this!!” another email said, encouraging doctors who were falling behind. These and other internal documents obtained by STAT expose the inner workings of UnitedHealth’s corporate strategy to enlist its doctors to pile moneymaking diagnoses onto patients covered by Medicare Advantage, the federal health care program for older adults that’s run by private insurers. With Tara Bannow, Bob Herman and Casey Ross, the next story in our series on UnitedHealth: https://lnkd.in/eaKf83if

Wondering how to protect yourself from Medicare fraud? If you have Original Medicare, your doctor SHOULD NOT: ◾ Charge you for most preventative services. ◾ Offer tests or other services that you do not need, especially if the doctor says that the more tests you receive, the cheaper they are. ◾ Routinely waive your coinsurance (providers can waive cost-sharing for patients with great financial need, but not regularly). ◾ Always confirm that you received the services listed on either your Medicare Summary Notice (MSN) or your Explanation of Benefits (EOB). Sometimes this can be hard to do if you received services from several doctors at the same time. ◾ If you returned durable medical equipment (DME), your supplier should not continue to charge Medicare for rental fees or maintenance. Visit our Medicare page for more information and resources to help you navigate all things related to Medicare and enrollment. https://hubs.ly/Q02-pw4X0 #Medicare #OpenEnrollment #Healthcare #MedicareInsurance #PatientCare #MedicareFraud