Is the New 2025 CMS Rule for Agent compensation actually GREAT news for AGENTS and FMOs?

[rmhaire]

Even you knew how ridiculous it sounded.

Actually both of you are right. There's fraud and waste on both sides.

I wouldn't trust either one out behind the outhouse with a muzzle on.

Edit: That's OM and MA. Not you and @somarco .

 

[somarco]

Yes, upcoding by providers occurs regardless of the third party payer. UHC controls roughly 10% of frontline provider practices and continues expanding their reach as part of their vertical integration strategy.

Why?

Simple . . .

“United’s one of the biggest providers in the country,” said Spencer Perlman, director of health care research at Veda Partners. “The insurance side has a cap on profitability. Providers don’t have that. So [United is] passing money from the insurance side to the provider side.”

The health insurer will see you now: How UnitedHealth is keeping more profits, as your doctor

The health insurer will see you now: How UnitedHealth is keeping more profits, as your doctor.

www.statnews.com

How many agents are not aware of this, or choose to ignore this information? Amazing how many are misinformed or uninformed about this industry.

One more thing . . . this thread is about CMS action and oversight for MA marketers and agents . . . not original Medicare.

 

[Midlevel]

Yes, upcoding by providers occurs regardless of the third party payer. UHC controls roughly 10% of frontline provider practices and continues expanding their reach as part of their vertical integration strategy.

Why?

Simple . . .

“United’s one of the biggest providers in the country,” said Spencer Perlman, director of health care research at Veda Partners. “The insurance side has a cap on profitability. Providers don’t have that. So [United is] passing money from the insurance side to the provider side.”

The health insurer will see you now: How UnitedHealth is keeping more profits, as your doctor

The health insurer will see you now: How UnitedHealth is keeping more profits, as your doctor.

www.statnews.com

How many agents are not aware of this, or choose to ignore this information? Amazing how many are misinformed or uninformed about this industry.

One more thing . . . this thread is about CMS action and oversight for MA marketers and agents . . . not original Medicare.

Try to explain all you want but still hilarious you are accusing MA plans of allowing upcoding but yet all I hear is how MA plans deny, deny, deny claims. There will always be 100 times more fraud in OM then Part C of Medicare. And I've never seen a thread stay on subject for 17 pages.

 

[sman]

Try to explain all you want but still hilarious you are accusing MA plans of allowing upcoding but yet all I hear is how MA plans deny, deny, deny claims. There will always be 100 times more fraud in OM then Part C of Medicare. And I've never seen a thread stay on subject for 17 pages.

Both things can be true. Physicians can upcode AND claims can be denied.

I just had a call a few weeks ago from a client who has bone spurs in his back. The MAPD denied the PA for surgery and is requiring 6 weeks of physical therapy before they will consider approving the surgery. There is no amount of physical therapy that will get rid of bone spurs in his back. So they want him to spend 6 more weeks in pain and pay for 18 physical therapy visits. I spoke to him last week and he said the physical therapy is making the pain worse.

With that said, are there doctors who will jump straight to surgery even if it isn't needed because that's more income for them? Absolutely. Does having PA for procedures potentially save the insurance company money? Most definitely. Is it always the right thing to do? Nope.

 

[somarco]

I wonder what the stats are on upcoding by providers when a managed care plan is the third party payer vs when OM is the payer.

Surely someone can authenticate the claim that upcoding and other types of fraud is 100x more prevalent vs MA providers. Why would anyone make such a silly claim without backup proof?

Perhaps anecdotes are more believable than facts.

Asking for a friend . . .

 

[David Puddy]

So will CMS ever clarify these new rules? Or are we left to just try and figure it out ourselves?

 

[Midlevel]

I wonder what the stats are on upcoding by providers when a managed care plan is the third party payer vs when OM is the payer.

Surely someone can authenticate the claim that upcoding and other types of fraud is 100x more prevalent vs MA providers. Why would anyone make such a silly claim without backup proof?

Perhaps anecdotes are more believable than facts.

Asking for a friend . . .

Google it, I don't have time as I'm headed to golf course.

 

[DonP]

So will CMS ever clarify these new rules? Or are we left to just try and figure it out ourselves?

Yes over the coming months carriers will ask cms for guidance . Finality of rules will be known by July 1st model probably and how carriers interpret them

 

[InsuranceGuy29]

Both things can be true. Physicians can upcode AND claims can be denied.

I just had a call a few weeks ago from a client who has bone spurs in his back. The MAPD denied the PA for surgery and is requiring 6 weeks of physical therapy before they will consider approving the surgery. There is no amount of physical therapy that will get rid of bone spurs in his back. So they want him to spend 6 more weeks in pain and pay for 18 physical therapy visits. I spoke to him last week and he said the physical therapy is making the pain worse.

With that said, are there doctors who will jump straight to surgery even if it isn't needed because that's more income for them? Absolutely. Does having PA for procedures potentially save the insurance company money? Most definitely. Is it always the right thing to do? Nope.

This is easily remedied with a note from the doctor and the physical therapist. A similar situation literally just happened about 2 months ago to a client of mine. They went to the first PA visit, gave it a try and said it hurt too much. They stopped. The PA informed the insurance company as well as the doctor. An appeal was filed, and it was immediately granted. This is what is always conveniently left out of the prior authorization arguments. How easily they’re remedied. The insurance company just wants to see that all logical steps are followed to rule out something as serious, and many times unnecessary, as a surgery. Surgery is a huge deal, and many times, doctors order these surgeries right away due to kickback deals they have in place.

 

[David Puddy]

Yes over the coming months carriers will ask cms for guidance . Finality of rules will be known by July 1st model probably and how carriers interpret them

Thanks Don!