Medicare Advantage criticized for denying care, overcharging

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Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the federal government billions of dollars every 12 months, government watchdogs told a House panel last week.

Witnesses sharply criticized the fast-growing health plans at a June 26 hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care, particularly those with high rates of patients who were disenrolled of their last 12 months of life while likely ill and in need of more services.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors shouldn’t be “required to leap through quite a few hoops” to achieve access to health care.

The watchdogs also really useful imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. Additionally they called for the Centers for Medicare & Medicaid Services, or CMS, to revive a foundering audit program that’s greater than a decade behind in recouping billions in suspected overpayments to the health plans, that are run mostly by private insurance firms.

Related to denying treatment, Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan had refused a request for a computed tomography, or CT, scan that “was medically mandatory to exclude a life-threatening diagnosis (aneurysm).”

The health plan required patients to have an X-ray first to prove a CT scan was needed.

Bliss said seniors “will not be aware that they could face greater barriers to accessing certain varieties of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, said seniors of their last 12 months of life had dropped out of Medicare Advantage plans at twice the speed of other patients leaving the plans.

Rep. Frank Pallone Jr. (D-N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to listen to that some patients are facing “unwarranted barriers” to getting care.

Under original Medicare, patients can see any doctor they need, though they could must buy a supplemental policy to cover gaps in coverage.

Medicare Advantage plans accept a set fee from the federal government for covering an individual’s health care. The plans may provide extra advantages, akin to dental care, and price patients less out-of-pocket, though they limit the selection of medical providers as a trade-off.

Those trade-offs aside, Medicare Advantage is clearly proving attractive to consumers. Enrollment greater than doubled over the past decade, reaching nearly 27 million people in 2021. That’s nearly half of all people on Medicare, a trend many experts predict will speed up as legions of baby boomers retire.

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James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care but “will not be meeting this potential” despite its wide acceptance amongst seniors.

Notably absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program. The agency took a pass though committee Republicans invited CMS Administrator Chiquita Brooks-LaSure to testify. Rep. Cathy Rodgers (R-Wash.) said she was “disillusioned” CMS had punted, calling it a “missed opportunity.”

CMS didn’t reply to a request for comment in time for publication.

AHIP, which represents the medical health insurance industry, released an announcement that said Medicare Advantage plans “deliver higher service, access to care, and value for nearly 30 million seniors and folks with disabilities and for American taxpayers.”

At Tuesday’s hearing, each Republicans and Democrats stressed a necessity for improvements to this system while staunchly supporting it. Still, the detail and degree of criticism were unusual.

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

On the hearing, the watchdogs sharply 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 paper than they’re. Bliss said Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments; she said 3.5 million members didn’t have any records of getting take care of medical conditions diagnosed during those health assessment visits.

Although CMS selected not to seem on the hearing, officials clearly knew years ago that some health plans were abusing the payment system to spice up profits yet for years ran this system as what one CMS official called an “honor system.”

CMS aimed to alter things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation,” or RADV. Health plans were directed to send CMS medical records that documented the health status of every patient and return payments after they couldn’t.

The outcomes were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by hundreds of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not accomplished audits dating way back to 2011, through which officials had expected to recoup greater than $600 million in overpayments brought on by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to release audits from 2011, 2012, and 2013 — audits the agency contends still aren’t finished. CMS is scheduled to release the audits later this 12 months.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with Policy Evaluation and Polling, KHN is certainly one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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