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Old man in nursing home
Of all the lies about Obamacare, there's one that has had the most longevity, the one that says the law cuts $716 billion from Medicare. It's also the lie that's been debunked the most frequently. It's not Medicare that's being cut, it's not people's benefits. It's the privatized Medicare Advantage program, an option people have to receive their Medicare benefits through private health plan. There are some very good reasons Medicare Advantage was the target for cuts in Obamacare—it has always spent a great deal more per patient than traditional Medicare, even though it has a generally healthier patient base. But, according to a year-long investigation by the Center for Public Integrity, Medicare Advantage plans bilked the taxpayers $70 billion in 2008-13 by exaggerating how sick their patients were.

The plans use "risk scores," a payment tool "which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health." This investigation uncovered a lot of questions about how these risk scores are being used, and how much federal money is being paid out on these errors.

Among the findings:
  • Risk score errors triggered nearly $70 billion in “improper” payments to Medicare Advantage plans from 2008 through 2013—mostly overbillings, according to government estimates. Federal officials refused to identify health plans suspected of overcharging Medicare, citing agency policy that keeps many business records confidential. The Center is suing to make these records public.
  • Risk scores of Medicare Advantage patients rose sharply in plans in at least 1,000 counties nationwide between 2007 and 2011, boosting taxpayer costs by more than $36 billion over estimated costs for caring for patients in standard Medicare.
  • In more than 200 of these counties, the cost of some Medicare Advantage plans was at least 25 percent higher than the cost of providing standard Medicare coverage. The wide swing in costs was most evident in five states: South Dakota, New Mexico, Colorado, Texas and Arkansas.
It'll be interesting to see if the Republican deficit hawks decide to deal with that, the end result of an experiment in privatizing Medicare. CPI tried to determine which insurance companies overbilled, but "officials who run the Medicare program repeatedly refused to be interviewed or answer written questions." The organization has filed a lawsuit to make that information public.

Originally posted to Joan McCarter on Fri Jun 06, 2014 at 09:47 AM PDT.

Also republished by Daily Kos.

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Comment Preferences

  •  Tip Jar (41+ / 0-)

    "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

    by Joan McCarter on Fri Jun 06, 2014 at 09:47:12 AM PDT

  •  probably. (4+ / 0-)
    Recommended by:
    Shockwave, hbk, IamGumby, occupystephanie

    Warning - some snark may be above‽ (-9.50; -7.03)‽ eState4Column5©2013 "If we appear to seek the unattainable, then let it be known that we do so to avoid the unimaginable." (@eState4Column5)

    by annieli on Fri Jun 06, 2014 at 09:49:24 AM PDT

    •  Oh, Annieli! (2+ / 0-)
      Recommended by:
      occupystephanie, Oh Mary Oh

      You beat me to it. Without reading anything but the headline, my answer, too, would have been, "Yeah, probably." Was your tone of voice kind of jaded, like mine was? :)

      "Seeing Leela fly off the Hexadecapus and crash through the moon dome and survive inside a stuffed animal by breathing a balloon was a dose of reality." Farewell, Futurama--I will avenge you!

      by IamGumby on Fri Jun 06, 2014 at 03:55:10 PM PDT

      [ Parent ]

    •  Maybe, maybe not (3+ / 0-)
      Recommended by:
      Simplify, KenBee, Oh Mary Oh

      I practice in New Mexico, and I may be one of these providers "overcharging" Medicare.  The reality is that risk scores are determined by a very complicated formula depending on identification of specific diagnoses, a list that runs into the hundreds.  The rules are extremely complex, and doctors and groups are slowly learning how to use them as they were intended.  As that happens, surprise!   Risk scores increase.  

      The rationale is supposedly to improve the quality of care by ensuring that the chosen diagnoses are not missed or neglected.  Because the list is partial, including many serious diagnoses but far from all, providers learn which diagnoses they need to code in order to increase payments.  Our group is doing this, and we have a large compliance program to make sure unwarranted diagnoses are not included.

      Increased risk scores make for increased payments to providers.  We use those increased payments primarily to improve services available to patients, like increasing drug formulary coverage, cutting co-pays and the like.  

      Medicare often identifies "fraud" where none exists.  There's plenty of Medicare fraud, but they've proven pretty poor at finding a lot of it.  This kind of report  commingles a lot of actual rule following along with an undetermined amount of real fraud.  And I don't doubt a lot of that "real fraud" comes from trouble following the baroque, poorly defined and communicated, and annually-changing rules they come up with.

      We have always been at war with al Qaeda.

      by Dallasdoc on Fri Jun 06, 2014 at 05:32:44 PM PDT

      [ Parent ]

      •  Right on, Doc. (2+ / 0-)
        Recommended by:
        Oh Mary Oh, Dallasdoc

        I practice in Colorado and my IPA has been teaching me how to code properly so that I reflect just how complicated my patients are.  I am routinely asked to prove that my coding is correct and so far, they only find that I still under code my patients.  

        Medicare dropped thousands of companies providing diabetic supplies from their rosters.  The remaining ones consistently send me emails stating my patients have requested their services when my patients are fine going to the local pharmacy to pick up their diabetic test strips.  So the companies they kept on the roster are rather dubious in my eyes.  What were the other guys doing?

        Medicare once threatened to put me on their "quack list" years ago, because I refused to treat an 88-year-old gentleman who had died.  They backed down when I demanded they prove the patient was indeed a modern day Lazarus first.  

        The biggest problem with Medicare is that it is a ginormous bureaucracy, and Heaven help us, President Obama loves bureaucrats.

  •  Medicare Advantage allowed many poor seniors (6+ / 0-)

    to access things like vision, dental and drug insurance that they could not otherwise afford. It wasn't all bad.

    "let's talk about that" uid 92953

    by VClib on Fri Jun 06, 2014 at 09:59:42 AM PDT

  •  Well, this helps me in my decision. (4+ / 0-)

    I turn 65 this summer, and retire this fall. As some of you know, that means my mailbox has been inundated with medicare advantage ads. My inclination has been to simply go with the government program. It seemed inefficient to pay medicare to pay an insurance company. I guess I'll go with that gut feeling.

    •  Don't confuse "Advantage" with "Supplemental." (4+ / 0-)
      Recommended by:
      leonard145b, cocinero, KenBee, Oh Mary Oh

      You don't get Silver Sneakers with things like AARP supplemental, for your additional $80 a month, but you don't have copays or share of costs or any of that.

      My only "disclosure" here is that I'm a nurse who gets Medicare and has been a VA medical care recipient for years. I am disabled (but still working 40  hours at nearly 70 years old), and I have signed up for the AARP Humana Plan F supplemental. Having had a number of "interventions" that would have cost a bundle even with Medicare straight, I can testify to Supplemental value. It is a great deal, about $180 a month all up (remember that even Medicare is not "free," it costs you about $120 a month now, one hell of a lot cheaper than any privatized policy for the coverage, day to day and catastrophic.)

      I spend a good part of my working day dealing with that effing "private 'health UNSURE-ance,'" where you are UNSURE whether any of your needs will actually be covered, without a war that may run all the way to "bad faith litigation," http://en.wikipedia.org/... , at least if you haven't been forced into a binding-arbitration clause that grossly favors the UNSUREer. So many situations where some asshole in a suit and a green eyeshade decides that, e.g., some procedure or treatment pr  critical medications will no longer be "covered," or on the "formulary" (happens every year with most plans, or more often, in part because of Part D and in part, Part G (for "GREED"). Or someone gets tricked by a salesperson into changing plans, "you can keep your doctors (not)." And then goes through the horror of being told that all their maintenance meds that have kept them going for years are suspended until they have "trialed" other cheaper meds in the same "class" of drug for a month or three, or if they are lucky their doctor may be allowed to do the "prior authorization shuffle," which is uncompensated time needed to fill out various forms "justifying" that medical judgment that the Death Panel assw__es otherwise worship (and you have to be sure to write "EXPEDITE!" in BLUE INK at the top of the appeal form, or it will take 14 to infinity business days to "process" the paperwork, and if you are using an increasingly mandated mail-order pharmascammery like (names deleted from fear of attorneys) it will take another 15 to 30 business days to actually bottle up and consign your pills and capsules and syrups and strips to the cheapest slowest Pony Express delivery. And the hours that get spent, first, just figuring out whether the pharmacy named on the pill bottle even still covers the patient's meds, which requires hacking your way through the "phone thicket," giving the same patient ID information to one computer and "patient service representative" after another to get that answer, and then making sure the script has the demanded detail on it so it won't get rejected, and finally talking to a pharmacist maybe about the meds in question, and confirming the address and fax number has not changed due to some corporate mumbo-jumbo profit-taking "reorganization" or "purchase" or other.

      Compare VA and much of Medicare, where your provider writes out or E-scribes the prescription to the captive pharmacy, and you either pick it up at CValgraMart or it arrives in the mail, in the VA case a 90 day supply for $9.

      Obamacare, as I am seeing it from the perspective of a small clinical practice, SUX and don't waste time telling me it's not so, it's giving all these new payers SOME kind of "health UNSURE-ance." The specialinterests are working hard to fuck up Medicare to force all of you, us, mopes into the gentle nutcracker of "private UNSURE-ance," which has NOT A GODDAM THING TO DO WITH HEALTH CARE, THE KIND OF STUFF THAT MOST NURSES AND DOCTORS WANT SO VERY BADLY TO PROVIDE. Big whoop that Obamacare will be 'taking the pressure off" efforts to give us all CIVILIZED single payer or even Swiss or German model actual health care. What a Success Story!

      You call it a "rant," maybe, I call it TESTIMONY and an absolute necessity to blow off the steam that having to find ways around the horror, every working day, builds and builds and builds.

      But back to my original point, the "Advantage" plans are the prequel to Obamacare, with everyone who's not blessed with a sane and kindly alternative now being forced into the JUNGLE of eat-you-alive-until-you-are-dead "privatized medical procedure payment plans." The Supplementals, so far, barring more fuckery by the Huge Privatizing Interests, are a pretty good deal.

      Why is it that so many of us are so stupid that the best we can do is hope that other people are more oppressed and impoverished than we are, and take such delight in stuff like the crushing of public and private labor unions, trashing teachers, and that Narrative that is tied to "bootstraps, which to reach them you have to bend over so the guys in suits can shove THEIR expensive Italian boots up your ass, then run around front and kick you in the teeth (and under most PLANS, you don't get any dental coverage, now do you? ANOTHER way to go insolvent...)

      PS:  "Patients sue Walgreens for making money on their data," http://www.healthcareitnews.com/... , and also "Which Drugstore Chain Is Most Likely To Overcharge You?", http://business.time.com/...

      "Is that all there is?" Peggy Lee.

      by jm214 on Fri Jun 06, 2014 at 04:53:27 PM PDT

      [ Parent ]

  •  They run up the "risk scores" to make more money (5+ / 0-)

    For profit health insurance doesn't work thanks to it's greedy CEOs and their entourage;


     photo b80a2441-25b2-4674-a969-f62600aef8a1_zps0df8272b.png

    Daily Kos an oasis of truth. Truth that leads to action.

    by Shockwave on Fri Jun 06, 2014 at 03:48:43 PM PDT

  •  My spouse worked for a home health agency (6+ / 0-)

    and observed first-hand that legitimate claims submitted for services, were far more likely to be denied by Medicare Advantage than they were by regular Medicare.  

    In other words, they were keep keeping the premiums but skimping on the services.  

    "The extinction of the human race will come from its inability to EMOTIONALLY comprehend the exponential function." -- Edward Teller

    by lgmcp on Fri Jun 06, 2014 at 03:50:49 PM PDT

  •  Umm, are "we" going to try and (1+ / 0-)
    Recommended by:
    occupystephanie

    recoup some/all of this "over billing"? Several years ago a local physician plead guilty to "over billing" medicare. His fines/penalties were a mere fraction of what he stole.

    Fuck me! He made it. Will Scarlet

    by dagolfnut on Fri Jun 06, 2014 at 03:51:28 PM PDT

    •  As I was told recently, the fact that private (2+ / 0-)
      Recommended by:
      occupystephanie, dagolfnut

      entities, companies or individuals, defraud the government is merely indicative of how ineffective government is.  Of course, private companies will steal if given the chance . . . that's capitalism at it's best.  

      "To conjugate in a future imperfect : will have been ongoing, once" -- Andrew Zawacki

      by Rikon Snow on Fri Jun 06, 2014 at 03:57:37 PM PDT

      [ Parent ]

      •  I guess if yer gonna steal one had better (1+ / 0-)
        Recommended by:
        Rikon Snow

        go big then.

        Fuck me! He made it. Will Scarlet

        by dagolfnut on Fri Jun 06, 2014 at 04:24:15 PM PDT

        [ Parent ]

      •  And "private companies" use their money to weasel (1+ / 0-)
        Recommended by:
        Rikon Snow

        their friends into power, into the positions where enforcement decisions are made and laws drafted, to make it ever eaaaasier to steal, and steal BIG. The War Department can't account for at least a TRILLION F___ING TAX DOLLARS, and they admit that they can't even be audited, nor can the Misdepartment of Homeland Unsecurity: http://www.huffingtonpost.com/... . That money goes to, errrr, PRIVATE COMPANIES who also spy on us, and sell weapons to all sides, like the Krupps did in the runup to and conduct of WW I and others like IBM did on the way into WW II. And do I even need to mention what we so absurdly call "Wall Street," you tell me where all those trillions went and are still going, into the paws of copro-ate-ist entities that are, per our Rulers in our fading Empire, TooBigToFu_kWith (TBTFW, guys and gals.)

        But hey, there are still small opportunities to be like the rats that ate the dinosaurs' eggs, and feces -- lookie here:

        "Florida Pharmacists Win $597 Million Blowing Whistle on Scheme",

         and it's from BLOOMBERG, for Haysus' sake:

        http://www.bloomberg.com/...

        "Is that all there is?" Peggy Lee.

        by jm214 on Fri Jun 06, 2014 at 05:07:02 PM PDT

        [ Parent ]

  •  Is anyone shocked that the changes wrought in 2003 (1+ / 0-)
    Recommended by:
    cocinero

    during the Bush administration resulted in more public dollars going to the pockets of for profit health care providers?

    Form follows function -- Louis Sullivan

    by Spud1 on Fri Jun 06, 2014 at 04:05:47 PM PDT

  •  Coburn to head VA? (0+ / 0-)

    No f'ing way

  •  Not to mention Medicare part : (0+ / 0-)

    Which was budgeted at $40 billion a year with no provision to fund except deficient spending.  These social conservatives just spend future taxpayers money like water.

    She was a fool, and so am I, and so is anyone who thinks he sees what God is doing. -Kurt Vonnegut Life is serious but we don't have to be - me

    by lowt on Fri Jun 06, 2014 at 04:40:17 PM PDT

  •  The other side of Medicare Advantage (0+ / 0-)

    Last year my pcp was dropped from my insurer's network. I decided to keep my doctor and change plans. Now my doctor has been dropped again and in mid-year. I have to either change doctors or do without until Jan 1, 2015 when I can change plans again.

    Meanwhile, I'm foregoing medical treatment that I think I can't afford. No one can tell me what my copay would be. Oh well, my blood oxygen saturation level never fell below 84 percent at night. I might survive if I awake every time it happens.

    Getting old ain't for sissies.

    I'm a Vietnam Era vet. I'm also an Erma Bombeck Era vet. When cussing me out and calling me names please indicate which vet you would like to respond to your world changing thoughts.

    by Just Bob on Fri Jun 06, 2014 at 05:16:42 PM PDT

  •  Really? (0+ / 0-)

    Another standard conservative run privatization that's committing fraud, bilking the public, and ripping off everybody?

    Surely you jest.

    I'm sure they've learned their lesson after the privatized prisons fiasco.

  •  Your First Clue (0+ / 0-)

    "Privatized".

    No government service should ever be privatized. When it's privatized, first, the taxpayers pay for the service, and then they pay for the profits.

    And then they get bilked on top of it, often enough.

    As in this case.

  •  Wealth (0+ / 0-)

    What is it about wealth that makes a persons heart grow cold and greedy?

  •  All good Pubbies know that the private (0+ / 0-)

    sector delivers higher quality services far more efficiently and at a far lower cost than the government...........except when the private sector doesn't.

  •  Medicare Part C Is A Sham (0+ / 0-)

    If you look back through the OIG's catalog of risk adjustment validation audits going back four years, not one Medicare "Advantage" plan identified for audit passed. There are certainly things I'd like to fix regarding Medicare Administrative Contractors and the way they pay and review claims for traditional Medicare coverage, but Part C is beyond help.

    "The game's easy, Harry" - Richie Ashburn

    by jpspencer on Sat Jun 07, 2014 at 06:40:16 AM PDT

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