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Sat Jul 31, 2021, 07:27 AM

US sues Kaiser Permanente over alleged Medicare fraud

Source: AP

SAN FRANCISCO (AP) — The federal government has sued Kaiser Permanente, alleging the health care giant committed Medicare fraud and pressured doctors to list incorrect diagnoses on medical records in order to receive higher reimbursements, officials said Friday.

The U.S. Department of Justice lawsuit, filed Thursday in federal court in San Francisco, consolidates allegations made in six whistleblower complaints.

Kaiser, based in Oakland, California, is a consortium of entities that together form one of the largest nonprofit health care plans in the U.S. with more than 12 million members and dozens of medical centers.

The lawsuit said Kaiser entities gamed the Medicare Advantage Plan system, also known as the Medicare Part C program, which gives beneficiaries the option of enrolling in managed care insurance plans, according to a statement from the U.S. Department of Justice.

Read more: https://apnews.com/article/business-health-medicare-566111a018e5e8f3d0224180050cbf0a

28 replies, 2294 views

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Arrow 28 replies Author Time Post
Reply US sues Kaiser Permanente over alleged Medicare fraud (Original post)
Omaha Steve Jul 31 OP
bucolic_frolic Jul 31 #1
C Moon Jul 31 #14
Grokenstein Jul 31 #2
PatSeg Jul 31 #3
Prof. Toru Tanaka Jul 31 #13
PatSeg Aug 1 #21
Prof. Toru Tanaka Aug 1 #22
PatSeg Aug 1 #24
oasis Jul 31 #4
DENVERPOPS Jul 31 #7
Demovictory9 Jul 31 #10
Dream Girl Jul 31 #12
C Moon Jul 31 #15
Dream Girl Jul 31 #16
C Moon Aug 1 #19
DENVERPOPS Aug 1 #20
CountAllVotes Aug 1 #25
DENVERPOPS Aug 1 #26
CountAllVotes Aug 1 #27
msfiddlestix Aug 1 #28
Casady1 Jul 31 #5
nitpicker Jul 31 #6
erronis Jul 31 #11
dalton99a Jul 31 #8
AllaN01Bear Jul 31 #9
Tikki Jul 31 #17
BadgerKid Jul 31 #18
disndat Aug 1 #23

Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 08:04 AM

1. Imagine what they do to the uninsured

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Response to bucolic_frolic (Reply #1)

Sat Jul 31, 2021, 05:04 PM

14. My wife got the COVID vaccine through them (as a non-member).

Then a couple months later, we got a bill from our insurance, that Kaiser is claiming the second dose was an anesthesia treatment.
:O
Okay, she showed up for a shot of anesthesia, then went home.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 08:12 AM

2. Good. I wonder if KP's still pushing Jenny Craig on patients.

Last time I went, my GP was very desperate to get me to sign on; I have to presume there were commissions for every sucker hooked.

But I had already seen Jenny Craig ads on late-night teevee promising "guaranteed" results--complete with an asterisk leading to a blurb of fine print negating the very same promise--and a mass-produced one-size-fits-all solution to a problem that is actually rather complex was already suspicious. You know how this game is played: they set you up to fail, and when it happens they say you didn't try hard enough. Still, a polite "hard pass" earned me a cold shoulder on the problem I came to see the doctor about in the first place.

Kaiser's specialists were great, but four out of five of the general practitioners I saw were primarily interested in pushing pills and plans. Gotta pay for that annual multimillion-dollar ad campaign to convince everyone that the HMO is "in the hands of doctors." (Wow, linked article is from 2002! They've been in trouble before.)

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Response to Grokenstein (Reply #2)

Sat Jul 31, 2021, 08:19 AM

3. Reminds me of going to Firestone to buy tires

and they try to sell you shocks and brakes. With retailers, it is annoying, but with medical professionals, it is very disturbing and unethical.

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Response to PatSeg (Reply #3)

Sat Jul 31, 2021, 03:29 PM

13. To me, Midas is the worst


when it comes to high-pressure "you need _____" to fatten the ticket. If I need muffler service, I'll go to Meineke or elsewhere.

I'm waiting for the day when I see my health insurance provider getting their hand caught in the cookie jar like this.

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Response to Prof. Toru Tanaka (Reply #13)

Sun Aug 1, 2021, 09:40 AM

21. Employees at such places are trained

to increase the customer average sale with add-ons, many of them unnecessary. Many years ago I took my Volkswagen Beetle to Firestone for a new set of tires. The mechanic started to rattle off a list of mechanical problems and when he got to "your automatic transmission fluid is leaking" I cracked up. "Seriously? It is a stick shift!" Realizing his mistake, even he started to laugh and just sold me the tires I'd asked for.

Unfortunately, I've had health care providers do similar things with additional and often redundant tests and procedures.

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Response to PatSeg (Reply #21)

Sun Aug 1, 2021, 11:20 AM

22. That's pretty good!


I guess there was nothing else to do but laugh at that "busted" moment. Like Mr. Lee on that old Calgon commercial when his wife exposed the "Ancient Chinese Secret".

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Response to Prof. Toru Tanaka (Reply #22)

Sun Aug 1, 2021, 12:21 PM

24. It was such a rare and priceless moment

One I never forgot and I'm sure he hated having to do this cheesy upsell with every customer.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 08:35 AM

4. Good. Bring the hammer down on those damn crooks.

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Response to oasis (Reply #4)

Sat Jul 31, 2021, 12:56 PM

7. If you want some real horror stories

about Kaiser just talk to any EMT who has ever dealt with a Kaiser Patient or Kaiser.



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Response to DENVERPOPS (Reply #7)

Sat Jul 31, 2021, 01:47 PM

10. Kaiser sux

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Response to DENVERPOPS (Reply #7)

Sat Jul 31, 2021, 03:26 PM

12. I've been a member for 25 years, had my son there and went through two major illneses

 

Nothing but great quality care and professionalism. My doctors are respectful, proactive and competent. If I need a test or procedure, I’ve never felt they balked or counted pennies. I wish people wouldn’t post about things they no nothing about!

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Response to Dream Girl (Reply #12)

Sat Jul 31, 2021, 06:13 PM

15. We were with them for a couple of decades...

and finally decided to get out. My wife had to go to a podiatrist outside of Kaiser to good treatment for plantar, she's fine now, but the Kaiser podiatrist was awful.

I think they are overburdened (in So. CA, anyway), and it's tough to find a good doctor. I had one of the worst experiences with a sit-in doctor while mine was out for a new baby (I liked the doctor I found, BTW), but the sit-in doctor was terrible! She did not want to be there, and talked down to me the whole time. I should have just walked out.

I do miss the easiness of procedures, blood tests, vaccines, etc. But I don't miss the care.

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Response to C Moon (Reply #15)

Sat Jul 31, 2021, 06:42 PM

16. I'm in NorCal, so maybe that's the difference? They've also changed a lot. Very procative

 

And the doctors work as a team.

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Response to Dream Girl (Reply #16)

Sun Aug 1, 2021, 02:03 AM

19. Thumbs up!

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Response to Dream Girl (Reply #12)

Sun Aug 1, 2021, 02:34 AM

20. I am glad

that you have had good experiences with Kaiser.

I will stop there.

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Response to DENVERPOPS (Reply #20)

Sun Aug 1, 2021, 12:35 PM

25. Good tolerance!

I hate hate hate these SOBs!

They did a real number on my late father.

Dad died and where the hell was Kaiser?

Dad was laying in a rehab. center as a vegetable while they were no where to be found due to a "nursing strike".

Uh huh.

FUCKERS.



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Response to CountAllVotes (Reply #25)

Sun Aug 1, 2021, 04:50 PM

26. Thank You CAV

I appreciate it...............

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Response to DENVERPOPS (Reply #26)

Sun Aug 1, 2021, 08:16 PM

27. Back at ya!



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Response to Dream Girl (Reply #12)

Sun Aug 1, 2021, 10:01 PM

28. I've have an excellent provider, and specialists have treated me very well

this round of being with kaiser is roughly 5 years. I have a fantastic doctor and he doesn't ever try and pull this crap on me.

Live in the North Bay, if that makes a difference.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 08:40 AM

5. Calling Ric Scott

This is your gig.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 12:30 PM

6. Link to the DoJ PR

https://www.justice.gov/usao-ndca/pr/government-intervenes-false-claims-act-lawsuits-against-kaiser-permanente-affiliates

(snip)
SAN FRANCISCO – The United States has intervened in six complaints alleging that members of the Kaiser Permanente consortium violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements.

The Kaiser Permanente consortium members (collectively Kaiser) are Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan of Colorado, The Permanente Medical Group Inc., Southern California Permanente Medical Group Inc. and Colorado Permanente Medical Group P.C. Kaiser is headquartered in Oakland, California.
(snip)

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the diagnoses of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with more severe diagnoses will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.

Medicare requires that, for outpatient medical encounters, MA Plans submit diagnoses to CMS only for conditions that required or affected patient care, treatment or management during an in-person encounter in the service year. In order to increase its Medicare reimbursements, Kaiser allegedly pressured its physicians to create addenda to medical records after the patient encounter, often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.
(snip)

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Response to nitpicker (Reply #6)

Sat Jul 31, 2021, 01:49 PM

11. Thanks for that link. I used to be a KP patient - it was fine for me but I didn't have real probs.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 12:58 PM

8. SIX whistleblower complaints

The lawsuit contends that Kaiser “pressured its physicians to create addenda to medical records,” often months or more than a year after an initial consultation with an enrollee, because more severe diagnoses for beneficiaries generally result in larger payments to the plan.

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 01:21 PM

9. here is the real medicare fraud and medicare queens .

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 07:45 PM

17. I wish there would be a class action, because I would be first in line.

Too much of a story to tell here, but.....


Tikki

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Response to Omaha Steve (Original post)

Sat Jul 31, 2021, 11:49 PM

18. Wonder if Medicare medical reimbursement rates

Make it a net loss. I’ve heard that’s the case for Medicare dental.

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Response to Omaha Steve (Original post)

Sun Aug 1, 2021, 12:02 PM

23. How about the DOJ calling

off investigations of nursing homes in NY, Pa, and Michigan covid deaths?

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