Managed care: Don’t give into ‘extortion’

DALLAS – Managed care plans have gotten a lot more active in auditing and, unfortunately, for providers they often operate under their own playbook, Wayne van Halem told Medtrade attendees on Tuesday. 

One thing, in particular, that he’s seeing: an increase in extrapolated overpayments, which are supposed to be appealable, but the plans don’t seem to understand that, he said. 

“What they’re doing is extortion: Pay this (extrapolated overpayment) or we’re going to audit you,” he said during his session, “Managed care messes: Audits wreaking havoc.” “It’s illegal what they’re trying to do. Once you bring it to light, they dig their heels in, pushing the payments and making things really challenging.” 

In 2023 alone, Medicare payments to Medicare Advantage plans totaled $454 billion, and with increased spend comes increased scrutiny. CMS is seeking more oversight over managed care plans, and the Office of Inspector General has identified them as a top priority for 2024. 

In the meantime, adding to the challenges for providers are “overzealous” audits and investigations, unclear and inconsistent appeal policies and rights, and difficult to no avenues for communication, van Halem said. 

“I think their strategy is just to overcomplicate it until providers just (give up) and say, ‘OK, we’ll pay it,’” he said. “I’m certain there are suppliers who do this, but don’t give into their demands.” 

van Halem said providers can protect themselves by understanding their appeals rights. They should also understand payer policies in advance; thoroughly review any contracts before executing; and maintain internal auditing and monitoring programs.