$31,474,228.80

[Packerland]

Just another reason that Medicare needs overhauled...Doctors with little to no oversight putting in reimbursements for unneeded lab work or test..

[EXTERNAL LINK] - Owner of Illinois company pleads not guilty, accused of making millions from Medicare

 

[GoPokes]

I spoke with a medsupp underwriter recently, who said the fraudulent billing is certainly a real issue. I was curious about the fraudulent DME claims, that consumers tell me about. Some of them will check their claims and notice the fraudulent bills that are being processed, such as the the back braces and such.

The underwriter said it is a real issue. medicare pays on them, and so does the medigap company. Medicare eventually flags it. and stops payments (to that provider), but that does not reverse the claims paid.

There must be a solution...

 

[Midlevel]

I spoke with a medsupp underwriter recently, who said the fraudulent billing is certainly a real issue. I was curious about the fraudulent DME claims, that consumers tell me about. Some of them will check their claims and notice the fraudulent bills that are being processed, such as the the back braces and such.

The underwriter said it is a real issue. medicare pays on them, and so does the medigap company. Medicare eventually flags it. and stops payments (to that provider), but that does not reverse the claims paid.

There must be a solution...

Can’t tell me Med Sups don’t wish certain tests, etc had PA like it should be. Imagine how much that would save these Med Sup companies and help keep premium increases down. Instead it’s a free for all and the Med Sups get screwed just like the taxpayers that pay for all the fraud.

 

[Packerland]

I spoke with a medsupp underwriter recently, who said the fraudulent billing is certainly a real issue. I was curious about the fraudulent DME claims, that consumers tell me about. Some of them will check their claims and notice the fraudulent bills that are being processed, such as the the back braces and such.

The underwriter said it is a real issue. medicare pays on them, and so does the medigap company. Medicare eventually flags it. and stops payments (to that provider), but that does not reverse the claims paid.

There must be a solution...

Clearly, pre-authorization is a viable solution to this issue. I concur with the original poster's view that companies providing medical supplements would prefer this approach to be more stringent. The most problematic are DME back braces. I frequently receive calls, often weekly, from call centers pretending to conduct a Medicare Survey. They inquire about any pain I'm experiencing. I usually go along with it and mention having back or lower body discomfort. At this point, they suggest I'm eligible for a back brace. However, when I inform them that I'm covered by an MA plan, they abruptly end the call.

 

[somarco]

fraudulent DME claims,

DME is one of the areas where prior authorization is required on almost every purchase. The "free" scooters that were heavily advertised a few years ago brought that on.



Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered.

The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner.

CMS maintains a Master List of DMEPOS Items that may be subject to one or both of the following prior to delivery:

a face-to-face encounter and written order
prior authorization requirements
The Master List of DMEPOS Items (PDF) is updated at least once per year.

https://www.cms.gov/data-research/m...-equipment-prosthetics-orthotics-and-supplies

 

[axeman462]

Government is bankrupt. Prior authorization will become more and more common as the debt burden grows. Pretty soon Somarco will be touting the evils of OM with a medsupp

 

[somarco]

Prior authorization with OM saves $$ for Medicare . . . PA for MA generates higher profits for the carrier while shifting the burden to the patient . . . either in higher costs for those who can afford to pay for the test/procedure or in delayed/denied treatment.

OM rarely employs PA because it is rarely needed. In addition to DME the PA process is used for certain surgeries such as blepharoplasty which can be cosmetic or medically necessary. Cosmetic surgery is denied, medically necessary approved.

Providers know that a claim denied by OM is a claim that will not be reimbursed and the patient is not responsible for paying unless they signed an ABN form.

PA under OM does not harm the patient but does limit the ability of the provider to bill for items that are not medically necessary.



Congress created private Medicare Advantage health plans to help control health care spending on the elderly. But a Center for Public Integrity investigation found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a “risk score.” Meanwhile, the growing power of the Medicare Advantage industry has muzzled many critics in Congress, and turned others into cheerleaders for the program.
[EXTERNAL LINK] - Medicare Advantage Money Grab Archives

PA with managed care plans creates more cash flow for the carrier and can limit access to necessary health care for the patient.

 

[Packerland]

I see this thread like most on here take on a life of their own… this has zero to do with MAPD plans .. it is about the lack of accountability on how Original Medicare has zero oversight until a crooked Doctor, Lab, or DME rips them off for millions of dollars. But hey let’s keep filibustering.

 

[rmhaire]

I see this thread like most on here take on a life of their own… this has zero to do with MAPD plans .. it is about the lack of accountability on how Original Medicare has zero oversight until a crooked Doctor, Lab, or DME rips them off for millions of dollars. But hey let’s keep filibustering.

So original medicare is causing all of the fraud and waste. Did I get that right?

Hell, since advantage plans seem to be fraud and waste free, maybe this article is fake news. Your turn to filibuster.

[EXTERNAL LINK] - ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions (Published 2022)

 

[axeman462]

So original medicare is causing all of the fraud and waste. Did I get that right?

Hell, since advantage plans seem to be fraud and waste free, maybe this article is fake news. Your turn to filibuster.

[EXTERNAL LINK] - ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions (Published 2022)

Just because MAPD does it too, doesn't make it right.