Medicare Advantage Insurer $100M Settlement

[somarco]

A New York health insurer and one of its former executives have agreed to pay the Justice Department up to $100 million to resolve claims that they made their Medicare members appear sicker than they really were to get more money from the government.

Certain diagnosis codes were routinely misused, Ross said. A common one was coding everyone over 70 with chronic kidney disease, even if their doctors hadn't diagnosed them, she said. Another was hypoxemia, or low blood oxygen levels. Ross said Gaffney instructed her team to apply that code to anyone with an order in their chart for oxygen equipment. And anyone with a prescription for a depression medication was coded as having major depression, she said.

Cigna agreed to pay the government $172 million in 2023 to settle allegations that it submitted inaccurate diagnosis codes for its Medicare Advantage members to inflate its payments and failed to correct them later on. That lawsuit, much like the October watchdog report, accused Cigna of adding diagnoses collected during home visits but for which patients didn't receive any treatment.

New York health insurer, executive agree to up to $100 million settlement over Medicare fraud tied to improper diagnoses

The insurer examined patient records to find money-making diagnoses and pressured doctors to sign off on them, according to the government's suit.

www.statnews.com

 

[annon123]

Not to mention, as an unintended (?) side effect, if Cigna (and likely others) do that to people it decreases their ability to pass medical underwriting (chronic kidney disease will likely do it all by itself) and will be trapped MAP's if they decide they want out; may not be able to buy other kinds of insurance that rely on medical history for access (for example long term care) or pricing. Sigh.

 

[rmhaire]

Not to mention, as an unintended (?) side effect, if Cigna (and likely others) do that to people it decreases their ability to pass medical underwriting (chronic kidney disease will likely do it all by itself) and will be trapped MAP's if they decide they want out; may not be able to buy other kinds of insurance that rely on medical history for access (for example long term care) or pricing. Sigh.

So where is the Griswold family today? I'm betting it's not in Mississippi.

And don't forget and leave Aunt Edna on the roof of the car.

 

[annon123]

So where is the Griswold family today? I'm betting it's not in Mississippi.

And don't forget and leave Aunt Edna on the roof of the car.

Aunt Edna? Heck my adult kid belongs there sometimes. And now it wouldn't even be child abuse (although to be fair I adopted her at 10 and there are some things you can not fix). There are good reasons why some species eat their young. LOL

The Griswold family made it fine to my destination up in the snow belt without causing havoc or being caught up in any. Aunt Edna got left at home so no worries about her. (grin)

 

[somarco]

may not be able to buy other kinds of insurance that rely on medical history for access (for example long term care) or pricing. Sigh.

At least one of my Medigap carriers relies on Milliman Intelliscripts (rxhistories.com) for the applicants medical history.

Milliman gathers medical CLAIM history using data submitted by insurance carriers. This includes commercial insurance (EGH, ACA) + MAPD + PDP but not original Medicare.

Health insurance carriers that falsely report claims for treatment for CKD, COPD, diabetes, etc are not only committing fraud but making it impossible for policyholders to be approved for underwritten health or life insurance.

I have run into this on numerous occasions over the last few years. Getting records changed and expunged is virtually impossible.

 

[goillini52]

A New York health insurer and one of its former executives have agreed to pay the Justice Department up to $100 million to resolve claims that they made their Medicare members appear sicker than they really were to get more money from the government.

Certain diagnosis codes were routinely misused, Ross said. A common one was coding everyone over 70 with chronic kidney disease, even if their doctors hadn't diagnosed them, she said. Another was hypoxemia, or low blood oxygen levels. Ross said Gaffney instructed her team to apply that code to anyone with an order in their chart for oxygen equipment. And anyone with a prescription for a depression medication was coded as having major depression, she said.

Cigna agreed to pay the government $172 million in 2023 to settle allegations that it submitted inaccurate diagnosis codes for its Medicare Advantage members to inflate its payments and failed to correct them later on. That lawsuit, much like the October watchdog report, accused Cigna of adding diagnoses collected during home visits but for which patients didn't receive any treatment.

New York health insurer, executive agree to up to $100 million settlement over Medicare fraud tied to improper diagnoses

The insurer examined patient records to find money-making diagnoses and pressured doctors to sign off on them, according to the government's suit.

www.statnews.com

Another reason to NOT do business with them.

 

[annon123]

At least one of my Medigap carriers relies on Milliman Intelliscripts (rxhistories.com) for the applicants medical history.

Milliman gathers medical CLAIM history using data submitted by insurance carriers. This includes commercial insurance (EGH, ACA) + MAPD + PDP but not original Medicare.

Health insurance carriers that falsely report claims for treatment for CKD, COPD, diabetes, etc are not only committing fraud but making it impossible for policyholders to be approved for underwritten health or life insurance.

I have run into this on numerous occasions over the last few years. Getting records changed and expunged is virtually impossible.

I keep asking Milliman Intelliscripts for a copy of what is in my records and they keep ignoring my request. You are supposed to be able to get one free copy a year. I need to see what in my mess of mistakes on me I am trying to clean up migrated there.

That is concerning as I am trying to clean up my medical records (EPIC is a disaster with all sorts of things in there that are wrong or in there multiple times and then people just copy/paste what from their old stuff which you thought you had cleaned up and then bingo, back where you started from) which sometimes is like playing whack-a-mole.

 

[MedicareWAA]

I think this is old news, no? From a couple of months ago?

 

[somarco]

@annon123 here is the link to request your medical history.

For Consumers - Milliman IntelliScript

www.rxhistories.com

There won't be a record for self-pay medical or Rx (including use of a discount card) since no claims were filed. Same for meds ordered from Canada which are also self pay and won't be reimbursed by a drug plan.

There also are no records for claims covered by Medicare or Medicaid.

What they will show is a record of insurance (health & life) applied for in the last 10 (?) years and whether coverage was approved or denied. If the application was rejected the report SHOULD show why the carrier denied coverage.

 

[annon123]

There won't be a record for self-pay medical or Rx (including use of a discount card) since no claims were filed. Same for meds ordered from Canada which are also self pay and won't be reimbursed by a drug plan.

There also are no records for claims covered by Medicare or Medicaid.

What they will show is a record of insurance (health & life) applied for in the last 10 (?) years and whether coverage was approved or denied. If the application was rejected the report SHOULD show why the carrier denied coverage.

Thanks. I thought they had record of claims too (eg non medicare). I guess the notes I took are wrong.