[JourneyOfLife]

FYI.

Story on NY Times Web site.

About a Health Insurance Co Whistle Blower and Medicare Advantage.

https://www.nytimes.com/2017/05/15/b...-medicare.html

[cbg150]

I just read this (https://www.nytimes.com/2017/05/15/b...-medicare.html)!
The Villages Healthcare needs to disassociate from Medicare Advantage immediately!

[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.

[JoMar]

The only reason I would question the article is because it's in the NY Times.

[golfing eagles]

Originally Posted by cbg150

I just read this (https://www.nytimes.com/2017/05/15/b...-medicare.html)!
The Villages Healthcare needs to disassociate from Medicare Advantage immediately!

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.

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.

[golfing eagles]

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.

"Kick backs"? Seriously?
No legitimate enterprise would go anywhere near violating the Starke laws in such a fashion. They MAY be receiving a royalty from UHC for allowing them to use the copyrighted "The Villages" name on their insurance plan.

And no one was "kicked out". People had a choice---stay with TVH and change insurance, or change providers. Those who were in love with their insurance plan, left. Those who loved their provider more, stayed and changed to MA. THEIR choice, no one put a gun to anyone's head. The ones who complain are those that wanted to have their cake and eat it too-----keep their plan AND their provider. This was not an option. This happens every year all across the country----providers change accepted insurance and insurers change participating providers----nothing new there, and those patients have to make the same choice as well.

[Dan9871]

Originally Posted by golfing eagles

This happens every year all across the country----providers change accepted insurance and insurers change participating providers----nothing new there, and those patients have to make the same choice as well.

Yup, my wife and I had employer provided health insurance with a choice of insurance companies before we retired to The Villages. At the end of every year we'd have check to see if the current plan we had still included our primary doc' who we really liked (in fact sometimes plan we had just went away). A couple of times we had to change our choice of insurance company to keep him, sometimes with a higher cost for our share. At least one time we lost a specialist because the plan we had no longer included him.