Medicare Advantage Insurer $100M Settlement

[somarco]

I thought they had record of claims too (eg non medicare).

They have a record of insurance claims, but not self pay. If one does not have insurance, as far as Milliman is concerned, there are no verifiable claims.

 

[goillini52]

They have a record of insurance claims, but not self pay. If one does not have insurance, as far as Milliman is concerned, there are no verifiable claims.

What about drugs through the VA?

 

[annon123]

They have a record of insurance claims, but not self pay. If one does not have insurance, as far as Milliman is concerned, there are no verifiable claims.

OK then I should have stuff in there. BSBC as an individual, not medicare related. Thanks.

 

[somarco]

What about drugs through the VA?

That is a govt entity, so I would assume that is like Medicare and Medicaid and does not report those "claims" to Milliman.

You can request a report and review it if you want. It has a LOT of detail.

 

[annon123]

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

Interesting - this was in 2023. More specifically, the 15-page lawsuit which was filed (Morris et al. v. Milliman, Inc.) says:

"The company, which operates as Milliman IntelliScript, has run afoul of the Fair Credit Reporting Act (FCRA) by publishing inaccurate medical and prescription history information, impeding consumers' efforts to correct errors by concealing the true sources of its data, and failing to reinvestigate after a consumer files a dispute."

The lawsuit filed is at the bottom of the page of the url below. Looking at updates the last report of status I can can find is Nov 2023, with class certification by July 2024.

Milliman IntelliScript Violated Consumer Reporting Law, Class Action Says

A class action lawsuit accuses consumer reporting agency Milliman, Inc. of violating federal law by failing to maintain reasonable procedures to ensure the “maximum possible accuracy” of its reports.

www.classaction.org

 

[somarco]

Unfortunately, medical records are notoriously inaccurate for any number of reasons. If I had to guess, I would say that upcoding results in a high percentage of incorrect medical records.

This report is 12 years old but I doubt things have changed much in that time.

https://www.annemergmed.com/article/S0196-0644(13)00101-7/fulltext

This 2021 report seems to confirm the problems associated with EMR and upcoding

UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING? - PMC

Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone. Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement. The ...

pmc.ncbi.nlm.nih.gov

 

[renee15]

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.

Interesting that Medicare Supplements are the ONLY health plan in the USA that is medically underwritten past Guaranteed Issue. Group and I Plans are not individually underwritten.