Latest News on the Medicare Program for Informed Seniors

Medicare Advantage criticized for overcharging

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital health care while charging the government billions of dollars each year, government oversight agencies told a House panel last week.

Witnesses harshly criticized the fast-growing health plans at a June 26 hearing by the Energy and Trade subcommittee on oversight and research. They cited a number of critical audits and other reports describing plans that deny access to health care, especially those with high rates of patients who were canceled during their last year of life while probably having a precarious health and needed more services.

Deputy Diana DeGette (D-Colo.), Chair of the subcommittee, said seniors should not be “forced to jump through numerous hoops” to access health care.

Watchers also recommended imposing limits on home “health assessments,” arguing that such visits can artificially inflate payments to plans without providing patients with proper care. They also called on the Medicare and Medicaid Service Centers, or CMS, to review an audit program that has been more than a decade behind in recovering billions of suspected overpayments on health plans. which are managed mainly by private insurance companies.

Related to the denial of treatment, Erin Bliss, deputy inspector general of the Department of Health and Human Services, said a Medicare Advantage plan had rejected an application for computed tomography or CT that “was medically necessary to rule out a diagnosis that it was life threatening. ” aneurysm). ”

The health plan required that patients have an X-ray first to show that a computed tomography was needed.

Bliss said seniors “may not be aware that they may face more barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the oversight arm of Congress, said seniors in their final year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving. the plans.

Representative Frank Pallone Jr. (DN.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to learn that some patients face “unjustified barriers” to receiving care.

With original Medicare, patients can see any doctor they want, although they may need to purchase an additional policy to cover coverage gaps.

Medicare Advantage plans accept a flat rate from the government to cover a person’s health care. Plans can offer additional benefits, such as dental care, and cost patients less out-of-pocket expenses, although they limit the choice of medical providers as compensation.

Aside from these compensations, Medicare Advantage is clearly proving attractive to consumers. Enrollment has doubled over the past decade, reaching about 27 million people in 2021. That’s nearly half of all people on Medicare, a trend many experts predict will accelerate as legions retire. of baby boomers.

James Mathews, who heads the Medicare Payments Advisory Committee, which advises Congress on Medicare policy, said Medicare Advantage could reduce costs and improve health care, but “does not meet that potential” despite its wide acceptance among the elderly.

Notably, on the hearing witness list was anyone from CMS, who runs the $ 350 billion annual program. The agency was approved even though Republicans on the committee invited CMS administrator Chiquita Brooks-LaSure to testify. MP Cathy Rodgers (R-Wash.) Said she was “disappointed” that CMS had turned down, calling it a “missed opportunity”.

CMS did not respond to a request for comment in time for publication.

AHIP, which represents the health insurance industry, issued a statement saying Medicare Advantage plans “provide better service, access to care and value for nearly 30 million seniors and people with disabilities and for American taxpayers. “

At Tuesday’s hearing, both Republicans and Democrats stressed the need to improve the program while firmly supporting it. Still, the detail and degree of criticism was unusual.

More commonly, hundreds of members of Congress argue against making cuts to Medicare Advantage and cite its growing popularity.

At the hearing, vigilantes harshly criticized home visits, which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can benefit from making patients look sicker on the role they are. Bliss said Medicare paid $ 2.6 billion in 2017 for diagnoses supported by health assessments alone; said 3.5 million members had no record of receiving care for medical conditions diagnosed during these health assessment visits.

Although CMS chose not to appear at the hearing, officials clearly knew years ago that some health plans were abusing the pay system to increase profits, but for years it ran the program as an official. of CMS called it an “honor system.”

CMS intended to change things from 2007, when it launched an audit plan called “Risk Adjustment Data Validation” or RADV. Health plans aimed to send CMS medical records documenting each patient’s health status and return payments when they could not.

The results were disastrous, showing that 35 of the 37 plans chosen for the audit had been overpaid, sometimes in the thousands of dollars per patient. The usual conditions that were exaggerated or could not be verified range from diabetes with chronic complications to major depression.

However, CMS has not yet completed audits dating back to 2011, through which officials hoped to recover more than $ 600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to publish audits of 2011, 2012, and 2013, audits that the agency believes have not yet been completed. CMS is scheduled to publish the audits later this year.

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