Commercial insurance companies offering plans through Medicare Part C and Medicaid Managed Care are called managed care organizations (MCOs). These companies contract with the government to administer Medicare Part C healthcare and submit the patient claims to the government. The reimbursement pay the doctors and other healthcare providers. All of the regulations applicable to Medicare and Medicaid apply equally to the MCOs.
To these companies, the government pays a flat rate based upon the patient ’ “risk scores.” These scores are based on the number of Medicare and Medicaid beneficiaries enrolled in a Plan as well as the patient’s degrees of sickness.
The reimbursements made by the government are fixed per-member-per-month payments to the Plans. The fixed payments are not altered by the amount of services a patient actually uses during the Plan year; Because patients with higher risk scores (i.e., those who are sick and have serious and/or chronic medical conditions) cost more to treat, the government pays higher rates for those patients projected to be sicker in the near future.
Hospitals and doctors, contract with certain MCOs to provide the patients with health care services. They bill MCOs for the medical services and procedures performed and get a share of the fixed rate paid by the government. Those bills, and medical records, contain diagnoses codes that correspond to the procedures and services provided.
The MCO’s have a duty to ensure that the data they submit are accurate, that the certifications they make are truthful. In some cases, MCO’s have submitted inflated invoices that were not based on truthful information about the services performed or the actual severity of the patient condition. In some of those cases, the companies had to pay the government over $100 million to settle the claims.
JEFFREY NEWMAN IS A WHISTLEBLOWER WHOSE FIRM HANDLES HEALTH CARE FRAUD ON MEDICARE AND MEDICAID UNDER THE FALSE CLAIMS ACT. HIS FIRM SITE IS WWW.JEFFNEWMANLAW AND HE CAN BE REACHED AT JEFF@JEFFNEWMANLAW.COM OR AT 617-823-3217
