Watchdogs Attack Medicare Advantage for Denying Care, Overcharging

By Fred Schulte, Kaiser Health News

Wednesday, June 29, 2022 (Kaiser News) — Congress ought to crack down on Medicare Advantage well being plans for seniors that generally deny sufferers very important medical care whereas overcharging the federal government billions of {dollars} yearly, authorities watchdogs advised a House panel Tuesday.

Witnesses sharply criticized the fast-growing well being plans at a listening to held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of crucial audits and different experiences that described plans denying entry to well being care, significantly these with excessive charges of sufferers who have been disenrolled of their final yr of life whereas probably ill and in want of extra companies.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, mentioned seniors shouldn’t be “required to jump through numerous hoops” to realize entry to well being care.

The watchdogs additionally advisable imposing limits on home-based “health assessments,” arguing these visits can artificially inflate funds to plans with out providing sufferers applicable care. They additionally known as 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 well being plans, that are run principally by personal insurance coverage firms.

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

The well being plan required sufferers to have an X-ray first to show a CT scan was wanted.

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

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, mentioned seniors of their final yr of life had dropped out of Medicare Advantage plans at twice the speed of different sufferers leaving the plans.

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

Under authentic Medicare, sufferers can see any physician they need, although they could want to purchase a supplemental coverage to cowl gaps in protection.

Medicare Advantage plans settle for a set price from the federal government for protecting an individual’s well being care. The plans could present additional advantages, reminiscent of dental care, and price sufferers much less out-of-pocket, although they restrict the selection of medical suppliers as a trade-off.

Those trade-offs apart, Medicare Advantage is clearly proving enticing to customers. Enrollment greater than doubled over the previous decade, reaching almost 27 million folks in 2021. That’s almost half of all folks on Medicare, a pattern many specialists predict will speed up as legions of child boomers retire.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare coverage, mentioned Medicare Advantage might decrease prices and enhance medical care however “is not meeting this potential” regardless of its broad acceptance amongst seniors.

Notably absent from the listening to witness record was anybody from CMS, which runs the $350 billion-a-year program. The company took a cross although committee Republicans invited CMS Administrator Chiquita Brooks-LaSure to testify. Rep. Cathy Rodgers (R-Wash.) mentioned she was “disappointed” CMS had punted, calling it a “missed opportunity.”

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

AHIP, which represents the medical health insurance business, launched an announcement that mentioned Medicare Advantage plans “deliver better service, access to care, and value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

At Tuesday’s listening to, each Republicans and Democrats harassed a necessity for enhancements to this system whereas staunchly supporting it. Still, the element and diploma of criticism have been uncommon.

More sometimes, a whole lot of members of Congress argue towards making cuts to Medicare Advantage and cite its rising reputation.

At the listening to, the watchdogs sharply criticized residence visits, which have been controversial for years. Because Medicare Advantage pays increased charges for sicker sufferers, well being plans can revenue from making sufferers look sicker on paper than they’re. Bliss mentioned Medicare paid $2.6 billion in 2017 for diagnoses backed up solely by the well being assessments; she mentioned 3.5 million members didn’t have any information of getting look after medical situations recognized throughout these well being evaluation visits.

Although CMS selected to not seem on the listening to, officers clearly knew years in the past that some well being plans have been abusing the cost system to spice up income but for years ran this system as what one CMS official known as an “honor system.”

CMS aimed to vary issues beginning in 2007, when it rolled out an audit plan known as “Risk Adjustment Data Validation,” or RADV. Health plans have been directed to ship CMS medical information that documented the well being standing of every affected person and return funds once they couldn’t.

The outcomes have been disastrous, exhibiting that 35 of 37 plans picked for audit had been overpaid, generally by 1000’s of {dollars} per affected person. Common situations that have been overstated or unable to be verified ranged from diabetes with continual problems to main despair.

Yet CMS nonetheless has not accomplished audits courting way back to 2011, by means of which officers had anticipated to recoup greater than $600 million in overpayments attributable to unverified diagnoses.

In September 2019, KHN sued CMS beneath the Freedom of Information Act to compel the company to launch audits from 2011, 2012, and 2013 — audits the company contends nonetheless aren’t completed. CMS is scheduled to launch the audits later this yr.

KHN (Kaiser Health News) is a nationwide newsroom that produces in-depth journalism about well being points. Together with Policy Analysis and Polling, KHN is among the three main working applications at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit group offering info on well being points to the nation.

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