Insurers Get $50 Billion For Fake Diagnoses But, Yeah, DPC Cherry Picks Patients

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Here is some interesting information. Originally reported in the WSJ, this article highlighted how insurance companies game the system.

Private insurance companies involved in Medicare Advantage — a government program in which private insurers oversee Medicare benefits — made hundreds of thousands of dubious diagnoses from 2018 to 2021 that triggered extra taxpayer-funded payments, according to an analysis by the Journal, and Medicare paid insurers around $50 billion for diagnoses added just by insurers to patient records.

“Any time you base a system like this on diagnosis codes, there’s going to be rampant abuse of the system,” he told the Journal. “[Insurers] will find something else to make up the revenue.”

Ah, the good old fake diagnoses codes trick. Doesn’t the AMA make money off this too?

First, these lowlife insurance companies were offering free home visits (not by doctors, of course) and a $50 gift card to pry themselves into the elderly homes. Anything to get new patients.

So, here is how the scam works. You get into the home and have a nurse find any information he/she can. And then this:

  • Medicare permits insurers to add their own diagnoses to ones submitted by patients’ doctors (how the hell was that allowed to happen? Who got paid off in Congress?)
  • In its analysis, the Journal says it found that some diagnoses were made that doctors were unaware of and patients received no care for, or that were apparently false. As an example, over 66,000 Medicare Advantage patients were found to be diagnosed with diabetic cataracts even though they already had gotten cataract surgery.
  • Meanwhile, another 36,000 diabetic cataract patients apparently didn’t receive any treatment related to diabetes.
  • Similarly, around 18,000 Medicare Advantage patients were found to be diagnosed with HIV through their insurers, but weren’t receiving treatment from their doctors. Each HIV diagnosis generated about $3,000 a year in added payments to insurers, according to the Journal.

Remember, these are the same insurance companies that continue to raise their astronomical rates while still being subsidized by the government.

And Direct Primary Care gets accused of cherry-picking patients? For $50 to $85 a month on average?

The next time they accuse you of cherry-picking tell them loud and proud your cost per month and that you take all-comers. Affordability and accessibility are the antidotes to the cherry-picking argument.

And can we please break up these damn insurance companies already? They are criminals.

About Douglas Farrago, MD

Dr. Farrago is a retired family physician based in Forest, Virginia. Since 2021, he has run DPCnews.com, a leading resource for the Direct Primary Care (DPC) movement. He is the author of three best-selling books on Direct Primary Care: The Official Guide to Starting Your Own Direct Primary Care Practice The Direct Primary Care Doctor’s Daily Motivational Journal Slowing the Churn in Direct Primary Care (While Also Keeping Your Sanity) In 2016, Dr. Farrago conceived the idea for the Direct Primary Care Alliance and co-founded the organization alongside other pioneering DPC physicians. He is widely recognized as a leading expert in the DPC model and frequently lectures to medical students, residents, and practicing physicians on how to successfully start and run their own DPC practices.Dr. Farrago sold his Direct Primary Care practice in October 2020 but continues to receive care there as a patient.