Independent primary care offices who outsourced their billing are now facing fraud charges

https://www.medpagetoday.com/primarycare/generalprimarycare/109083?xid=nl_mpt_DHE_2024-03-10&eun=g2225995d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Evening%202024-03-10&utm_term=NL_Daily_DHE_dual-gmail-definition

It is always best to keep your business in house when you do private practice. There are currently 19 states, with 6 states being in the biggest hot water, for illegally overbilling and overdiagnosing Medicare patients in order to get higher reimbursements paid to them. What is not entirely clear is did the providers and their offices KNOW this was happening or not?

Aledade is a company that “runs” practices for the healthcare provider. They manage their billing, streamline patient care, and market themselves as “we will take care of the business so you can focus on patients”. I won’t lie, that is an appealing option, because running the business side takes a ton of work, and you have to hire people to do that. So what these small practices did was hire Aledade to do this for them. There are tons of companies out there who offer this benefit. But Aledade has some big red flags.

“Aledade was co-founded in 2014 by Farzad Mostashari, MD, a former health information technology chief in the Obama administration, and has welcomed other ex-government health figures into its ranks. In June 2023, President Joe Biden appointed Mandy Cohen MD, MPH, then executive vice president at Aledade, to head the CDC in Atlanta.”

They love to live off federal government dollars (Medicare) and what they are doing is making patients diagnoses worse, adding on ailments that pay better, and increasing the money that providers make, which in turn make Aledade more money because most of these companies get paid a percentage of what they bill for you. So for example, if you have a patient with diabetes, you chart it as obesity, uncontrolled diabetes, and throw in depression because Medicare will pay you more for these 3 ailments than for just controlled diabetes. The provider makes a greater reimbursement, and Aledade makes more money as well. If Aledade gets 5% of what they bill for a patient, and Aledade took a standard stable diabetic patients chart and submitted a bill for $100, they are only getting $5 for that. But if they tack on “uncontrolled” diabetes, obesity, and depression, well that visit just went up to $500 and Aledade just made both of you more money.

I find it hard to believe providers were not complicit in this, as it appears on their website that they offer courses to providers on how to “bill and code a visit”, and it appears Aledade has a list of billing codes they want you to use.

Stay tuned.