As the manager of a union benefit plan - self insured - we do have a program of intensive bill review as well as normal claims processing reviews - we do see some "upcoding", too - perhaps not to the degree that CMS does for Medicare or states do for Medicaid. We see significant "unbundling" by many hospitals/health systems - where they bill for services that should be part of the bundled charge. We suggest that the DOJ should look at that, too.
I don't trust anything this DOJ does. Yes, no doubt there are ongoing shenanigans by UHC and the like... but I don't trust this DOJ not to use this situation as a way that could eventually limit, restrict, or outright deny REAL serious, undiagnosed medical issues and their necessary interventions.
Disgusting. I hate all the senators and congressmen— they do nothing all day but take full benefits( healthcare better than yours) and salary( possibly more than yours). These people ARE the fraud and abuse in Washington!!!!.
Help me LOL yesterday I received an email from my private for-profit health insurance inviting me to invest in my health and join Wellabe rewards program. Of course this was after they raised my monthly premium.
We deserve healthcare free of all middlemen & therefore free of all profit.
If these added diagnoses are unsupported by medical evidence or not actively treated, they should be considered upcoding, as they inflate reimbursement without reflecting actual care.
That money should be clawed back and a fine levied.
Incentivizing Providers and vendors like DxID to seek out further diagnoses in order to get a more complete view of the whole patient probably isn’t illegal, or even immoral, unto itself.
However, proper checks and balances need to be in place to avoid things like the $100m settlement reached for this very thing with DxID and Independent Health, another MA insurer.
As the manager of a union benefit plan - self insured - we do have a program of intensive bill review as well as normal claims processing reviews - we do see some "upcoding", too - perhaps not to the degree that CMS does for Medicare or states do for Medicaid. We see significant "unbundling" by many hospitals/health systems - where they bill for services that should be part of the bundled charge. We suggest that the DOJ should look at that, too.
I don't trust anything this DOJ does. Yes, no doubt there are ongoing shenanigans by UHC and the like... but I don't trust this DOJ not to use this situation as a way that could eventually limit, restrict, or outright deny REAL serious, undiagnosed medical issues and their necessary interventions.
I agree.... since our founding it's been mostly about ensuring the wealthholders do well no matter what it takes.
Grand theft of wage wealth from the lower / middle class.
Upcoding and incentives to doctors for keeping down the costs to
insure Healthcare remains the #3 sector on Wall Street. Market Cap is still $7.2 Trilllion.
We need the DOJ to investigate the ACO REACH program on how much doctors' bonuses are who participate with patients in Traditional Medicare.
Profit first, Care maybe?!?!?!
Part C plans aka private-for profit insurance companies get a corporate welfare raise in 2026 to the tune of 5.06%
Disgusting. I hate all the senators and congressmen— they do nothing all day but take full benefits( healthcare better than yours) and salary( possibly more than yours). These people ARE the fraud and abuse in Washington!!!!.
This has been going on for decades! Ask Rick Scott and WellCare! And it is our tax dollars!
Wendell thanks for helping.
Help me LOL yesterday I received an email from my private for-profit health insurance inviting me to invest in my health and join Wellabe rewards program. Of course this was after they raised my monthly premium.
We deserve healthcare free of all middlemen & therefore free of all profit.
Here's the consequence of Medicare Advantage thievery: https://www.thestreet.com/retirement/retired-workers-to-see-shocking-change-to-medicare-in-2026?fbclid=IwQ0xDSwLbeRljbGNrAtt5EGV4dG4DYWVtAjExAAEe9QUqPTwdrOOmCZf4YOluHE01SrZNhe80wW7MBUscCZfzEZSkFrOLeXTzOOs_aem_pA1I850_bf-SxjzhjGkmJg
This one seems pretty black and white to me.
If these added diagnoses are unsupported by medical evidence or not actively treated, they should be considered upcoding, as they inflate reimbursement without reflecting actual care.
That money should be clawed back and a fine levied.
Incentivizing Providers and vendors like DxID to seek out further diagnoses in order to get a more complete view of the whole patient probably isn’t illegal, or even immoral, unto itself.
However, proper checks and balances need to be in place to avoid things like the $100m settlement reached for this very thing with DxID and Independent Health, another MA insurer.
That’s a fantastic AI use case.
It will be interesting to see how this plays out.