Advantage plans took an estimated $11.4 billion in fraudulent & erroneous payments from Medicare in 2022, only the most recent of nearly a decade of growing annual figures involving one of the most profitable of American insurance industry sectors.
...“This isn’t a partisan issue,” said Sen. Sherrod Brown (D-Ohio). “I’ve requested a plan from CMS as to how they plan to recoup these taxpayer-funded overpayments and prevent future overbilling.”…
...Sen. Chuck Grassley (R-Iowa) called for “aggressive oversight” to recoup overcharges. “CMS must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments...”
The obvious root of the problem on the industry end is profit. The apparent root of the problem on the government end is that Medicare is only set up for annual audits of about 5% of Medicare Advantage plans routinely.
Dara Corrigan, a CMS deputy administrator, said that as a “general matter,” its Medicare Advantage audits “are not designed to detect fraud, nor are they intended to identify all improper diagnosis submissions.”…
KHN.org permits free republishing of their articles on this matter —e.g., “How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions” — but they’re too long and heavily detailed to do that in DK. To start with, though, KHN filed a a Freedom of Information Act lawsuit to obtain exclusive release of a review of 90 government audits that together showed health insurers issuing Medicare Advantage plans to have repeatedly sought to sidestep regulations requiring documentation of medical conditions the US government paid them to treat 2011-2013.
...The costs to taxpayers from improper payments have mushroomed over the past decade as more seniors pick Medicare Advantage plans. CMS has estimated the total overpayments to health plans for the 2011-2013 audits [alone] at $650 million, yet how much it will eventually claw back remains unclear...
Medicare was never adequately equipped with the teeth necessary for vigorously clamping down on Advantage-plan fraud, neither preventively nor punitively. The insurance industries, however, vigorously advanced the concept —popularly called Medicare “Part C” — and recruited the support of disabled people and seniors and their families, with promises of
coverage that meets or exceeds the standards set by the other parts, but they do not have to cover every benefit in the same way (actuarial equivalence is required). Plans must be approved by the Centers for Medicare and Medicaid Services (CMS). If a MA plan reduces some benefits, the savings may be passed along to consumers by lowering co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).[2] Coverage must include inpatient hospital (Part A) and outpatient (Part B) services. Typically, the plan also includes prescription drug (Part D) coverage.[3] Many plans also offer additional benefits, such as dental coverage or gym membership...
You begin to get the picture, if you hadn’t long since. So, here’s the DK tag for diaries about or including the topic of Medicare Advantage. And for readers unfamiliar with KHN’s nonprofit public-interest health-policy&medical-sector publishing, here’s the wikipedia article: Kaiser Health News comes from the Kaiser Family Foundation, NOT affiliated with or connected to —thank god — KaiserPermanente, or KaiserPermanenteVentures (the for-profit investment arm of the for-profit KP branch that constitutes all physicians there).
...Through KHN (Kaiser Health News), KFF's editorially independent news service dedicated to coverage of health care policy and politics,[11] KFF provides coverage of health policy issues and developments at the federal and state levels in the health care marketplace and health care delivery system.[12] ...
KFF also sponsors training and site visits for health care reporters….
...KFF publishes analysis, polling and journalism about health-care issues, and states that much of its work especially concerns persons with low income or those who are otherwise especially vulnerable to health-care cost, such as the uninsured, those with chronic illnesses, or Medicaid/Medicare recipients. In addition to domestic U.S. health policy issues, KFF also conducts work on the U.S. role in global health policy....[6]
...[KFF/KHN] is well known for public opinion research, documenting the views and experiences of the public on health and related issues – often in partnership with major news organizations, such as The Washington Post[9] and The New York Times.[10]...