Government Auditor Finds Billions in Improper Payments to Medicare Advantage Plans--

[eridani]

--Coupled with Inadequate Oversight by Federal Regulator

http://www.gao.gov/assets/680/676441.pdf

This week the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments. The report states that the Centers for Medicare & Medicaid Services (CMS) estimates that about 9.5% of its annual payments to Medicare Advantage (MA) organizations were improper – totaling $14.1 billion in 2013 alone – “primarily stemming from unsupported diagnoses submitted by MA organizations.” This plan-initiated billing practice is commonly referred to as “upcoding” when an MA plan reports an enrollee as being more sick than they actually are in order to obtain a higher risk-adjusted payment from the Medicare program. The report also highlights the significant flaws in CMS’ current efforts to address and recoup such payments.

The Center is deeply troubled by these ongoing improper payments to MA plans and CMS’ lack of progress in recouping previous payments and deterring future misconduct. In an NPR story about the GAO report, “GAO Audit: Feds Failed To Rein In Medicare Advantage Overbilling” (May 9, 2016) the Center is quoted as stating: "We hope that policymakers who protect MA (Medicare Advantage) profit at all costs, while at the same time often proposing to shift more costs on to the majority of beneficiaries in traditional Medicare, take heed of this GAO report and ensure that the recommendations are implemented."

[Wounded Bear]

1. And the Repubs will blame the government...

when it is the insurers that are committing fraud.

[ReRe]

6. Exactly.

And it has nothing to do with the ACA. But how much you want to bet they won't blame it on the ACA?

[Enthusiast]

7. Just as we have come to expect.

[SheilaT]

2. Probably the response will be to shut down all Advantage planes.

I have one, and I'm very fond of it. It covers all the standard Medicare stuff plus a bunch of extras. It's what all health care should be. Well, considering I'm an extremely healthy person, that may not be accurate, but no one should be out of pocket any more than I am, even if they have serious medical issues.

I'm also under the impression that there's an intention to eliminate all Advantage plans in the near future. I hope not.

[eridani]

3. Probably not the ones that don't cost more

I have one with Group Health which isn't any more expensive than the standard plans.

[grasswire]

4. many advantage plans are nothing but fluff

The real gems are medigap plans, where the coverage is standardized by government decree no matter who the insurer is. Carriers can't get away with fluff with medigap. The downside is that there is a small window of opportunity to sign up for medigap and if that is missed, it is difficult to get in.

[SheilaT]

5. My Advantage plan is not fluff, and it doesn't cost me anything

more than the $104.90 (or whatever the exact amount is) that is deducted from my SS payment every month. It covers all the basic Medicare stuff, plus a whole bunch of extras, most of which I've forgotten about because I've had them long enough. Let's see, zero copay on routine office visits, zero copay on routine blood tests, zero copay on the three meds I take -- fortunately they are basic generic ones, lucky me. Oh, and a $20/month (it used to be $50 and I'm hacked off that it got reduced) credit on various items like toothpaste, toothbrushes, aspirin, bandaids, stuff like that.

Yes, I need to stick with doctors within my plan, but for me that's not an issue since I'm not currently needing any specialists. A close friend, a few years older than I am, has a similar Advantage plan that she pays extra for, I think around $60/month, but it allows her to choose her doctors. She has more health issues than I do, so for her it's likewise great.

I do not want to see Advantage plans go away any time soon.