New York Sees Settlement in Medicare Advantage Whistleblower Case – Discover the Details!

[Chris]

U.S. authorities have announced a settlement in a whistleblower case involving a New York health insurer accused of defrauding the federal Medicare program. The insurer allegedly inflated the severity of its members' illnesses to enhance profits. This development raises important questions about the integrity of such health programs.

What are your thoughts on how these types of settlements affect the insurance industry as a whole?

You can [read the original story here](https://www.insurancejournal.com/news/east/2024/12/19/805579.htm) for more details.

 

[somarco]

This might get more play in the Senior Insurance Forum . . .

 

[Chris]

This might get more play in the Senior Insurance Forum . . .

Good call

 

[annon123]

U.S. authorities have announced a settlement in a whistleblower case involving a New York health insurer accused of defrauding the federal Medicare program. The insurer allegedly inflated the severity of its members' illnesses to enhance profits. This development raises important questions about the integrity of such health programs.

What are your thoughts on how these types of settlements affect the insurance industry as a whole?

You can [read the original story here](https://www.insurancejournal.com/news/east/2024/12/19/805579.htm) for more details.

Despite the rule changes if it still going to need to whistleblowers to catch them then nothing much is going to happen. There needs to be put in place a system that makes something like more likely to come to light although what that system would be I do not know. It seems to me stuff like this would be very hard to catch without an insider. Certainly increasing penalties would serve as a deterrent but it still may be hard to actually catch, in a provable way, this is still going on.

The bigger problem is how the system is manipulated to get more money. And it isn't just a problem of trying to get more income the way the article discusses. Upcoding time spent with a patient and ordering unnecessary tests to help upgrade the coded seriousness of their issue goes on too.

A local catholic non-profit has outsourced their ER to a for profit company. The ER medical group has a "mandate to have $1200 in billable charges for each patient who crosses the doorstep." Why? So they can upcode the severity so the pro profit company has more money coming in.

That is a direct quote of a frustrated staffer who wasn't going to make the mandate with a patient (and apparently in this case might miss making quota for the shift) because the patient was turning down unnecessary tests (that yes that patient knew they were unnecessary as they were familiar with their condition and knew what needed to be done). Then in the visit notes the ER MD lied about what went on. The *** MD forgot that if the patient had had an IV there would have been a hospital charge for that. There wasn't.

And as a side issue doing this - both in a more systematic way with diagnoses as in the whistleblower case, and at times pulling the upcoding stunt - is going to prevent some people from passing medical underwriting. Of course that chains those patients to the MAP if they ever decide they want out of their MAP (which I hope someone in implementing these changes is thinking about). Not to mention it will cost the patient more in many cases with copays. And we wonder why some patients have so much medical debt. This kind of stuff doesn't help. Sigh.