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Originally Posted by cbg150
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Quote:
Originally Posted by Topspinmo
Not as long as they are getting kick backs. When the well goes dry they will be begging for all the Medicare people the kicked out to ccme back.
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OK guys, please get a grip on reality. Did anyone actually read the article?
Here's the nuts and bolts of this guys frivolous allegation: Insurance companies scour the data to code for the most financially advantageous diagnostic codes. No kidding. So does every hospital, doctor, pharmacy, nursing home and durable medical equipment provider. You would have to be an idiot not to. CMS has set up payment rules based on diagnoses and complications, so as long as the patient actually has that diagnosis, they are following the rules. I saw nothing in his allegation that suggested the insurance company was making up the diagnosis, just that they were "data mining" to find them. Meanwhile, by acting as a "whistle blower", he could potentially gain millions in "finder's fees"
From the article:
Mr. Poehling said the data-mining projects that he had monitored could raise the government’s payments to UnitedHealth by nearly $3,000 per new diagnosis found......He included in his complaint an email message from Jerry J. Knutson, the chief financial officer of his division, in which Mr. Knutson urged Mr. Poehling’s team “to really
go after the potential risk scoring you have consistently indicated is out there.”
So, he was instructed to look for diagnostic codes that they knew were "out there", not to make them up.
Say you look in your pocket and find a penny from 1909. You go to a coin value source and find it is worth 2 or 3 dollars. You also find that if it is a 1909 S, it is worth $85, but if it is a 1909 S VDB it is worth $10,000. So do you take a magnifying glass to "data mine" that penny for "financial gain", or do you just list it on E Bay for $2? I'll bet you would consider yourself prudent and smart for carefully checking out that coin, and consider anyone who doesn't a total moron. Yet, when an insurance company does EXACTLY the same thing---"data mine" their patient population for the true value of what is already there, you consider them criminal frauds. Seriously??? Get real.