Medicare Advantage and Medicare Fraud – DOJ’s new target for enforcement?

Whistleblower lawsuits have been the tool of choice for the Department of Justice (DOJ) to identify and enforce Medicare Fraud.  Based on the levels of fines reported, it appears that many fraud claims are frivolous or the fines were so small that they don’t make much news.   Therefore, the two claims of Medicare Fraud by […]

Medicare Advantage Fraud – Risk Reward incongruity hinders enforcement

Department of Justice just certified Ben Poehling’s Whistleblower lawsuit and are suing United Healthcare for $1.14 billion for 2011-2014.  Absent any additional information, this looks like a huge fine and likely a big win for the DOJ if they are successful.  When context is added to the equation, what the DOJ is suing for appears […]

Medicare Advantage fraudulent payments from CMS – Potential solutions to a systemic issue

The shift from a flat Medicare Advantage premium rate to a dynamic one with Risk Adjustment Factors (RAF) was a good idea by CMS.  The program created an incentive system where seniors with more healthcare conditions were less likely to be discriminated against by MA Plans in favor of healthy, low risk seniors.  The challenge […]

Healthcare executive innovation required in a post Affordable Care Act world

The Patient Protection Affordable Care Act’s (PPACA) future is uncertain as the Republican Majority have spent the last seven years attempting to repeal the legislation.  While the Democrats and Republicans engage in a lively debate and political processes to substantiate their respective party’s platform on the legislation, this is the time for healthcare executives to […]

Primary care physicians – Solution or Chattel

How are PCPs perceived in the healthcare system? PCPs appear to be viewed as the necessary expense by hospitals and insurance companies. Specialists see PCPs as s referral source. RBRVS measurements are lower for PCPs than specialists. This creates the question on whether PCPs are the solution or chattel. Managed care has stereotypically viewed PCPs […]

Population Healthcare and the impact on ACO Benchmarks

Accountable Care Organizations have become quite popular alternative to Medicare Advantage Plans, yet a tiny percentage of the Medicare Shared Savings Program (MSSP) ACOs are earning the lion’s share of the bonuses. This phenomenon is unlikely to change until the ACO embraces Population Healthcare principles in the management of their patient’s care. To level set, […]

How to define Population Healthcare

What does population healthcare mean? The term Population Healthcare is used by the vast majority of healthcare executive and politicians, yet if asked the definitions are completely different. The Affordable Care Act (PPACA) in it’s 906 pages, does not even address the term Population Healthcare. The challenge is that the healthcare system is left to […]

How CMS determines revenues for Medicare Advantage and Accountable Care Organizations

Insurance products are historically based on a set amount of revenue every month for each insured person. When dealing with government sponsored products such as Medicare Advantage (MA) and Accountable Care Organizations (ACO), this number is variable. Understanding how revenue is determined by CMS helps MA and ACO plans enhance their topline from the members […]

CMS Quality Measurements for Medicare Advantage, the Red Herrings of healthcare

Quality metrics built into the regulations by CMS have become the norm.  These measurements are set to improve or be a proxy quality healthcare.  Measuring outcomes is designed to modify the behavior of health plans, hospitals and physicians to adopt quality in their organizations.  It is highly unlikely that any of these entities are purposely […]