Medicare Advantage crackdown!

[Greenbeard]

All the links are behind a paywall. I’ve read about this from another source (see below) and it was based on rather old (2013 and before) data and listed two (out of ???) MA plan providers as being ‘major offenders’.

https://www.npr.org/sections/health-shots/2022/11/21/1137500875/audit-medicare-advantage-overcharged-medicare

The problem is well-documented and the subject of numerous ongoing legal actions.

But a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles, over the course of four presidential administrations.

One company, Mobile Medical Examination Services, worked with Anthem and Molina, among others. Its doctors and nurses were pushed to document a range of diagnoses, including some — vertebral fractures, pneumonia and cancer — they lacked the equipment to detect, according to a whistle-blower lawsuit. . . Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted.

In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

A civil trial accusing UnitedHealth of fraudulent overbilling is scheduled for next year. The company’s internal audits found numerous mistakes, according to the lawsuit, which was joined by the Justice Department.

 

[dockside]

Interesting. The other week you were bragging to me how Medicare costs have been falling relative to earlier projections.

So, that coincided with an expansion of the portion of the Medicare populace that was choosing a more privatized option?

Huh. Well Whattya know

The part of the populace that chose Advantage is very uninformed about what Advantage is. It is an HMO. You have to go to their preferred providers. Altho' premiums are lower, the subscriber will pay through the nose for deductibles and co-pays. And, the insurance company gets to decide whether to approve treatment for their subscribers, unlike Medicare supplement plans. The largest Advantage plan provider, United Health Care, has been sued by the feds for fraud more than once. It is a great money maker for the insurers. United Health Care last year made over $21 BILLION in profits. And, I know all this because I was beguiled by the low premiums only to pay over $4,000 one year in deductibles and co-pays for my husband who had so many hospitalizations for triple bypass and the resulting MRSA. And, we were lucky to be able to switch to a Medicare supplement plan (they wouldn't pay anything for the first three months so we were able to abstain from seeing any doctors for that time and very lucky neither of us needed hospitalization). Most people, unless they are very healthy (well, you usually are when you are 65 but not nearly as healthy when you turn 75) are much better served by regular Medicare Parts A, B and D and a supplemental plan.
Here's an article that tells you why Advantage insurers can make tons of money and don't necessarily need to attend to your medical needs: https://www.whistleblowerattorneys.com/blog/whistleblower-unitedhealth-medicare-advantage-fraud

And here is another quite long, but revealing story of how Advantage insurance companies operate to make their profits off in an HMO setting. It is about a college student and his life-threatening disease and how United Health Care refused to cover the very expensive prescription necessary to treat him, even tho' his Mayo Clinic doctor, known to be the best of his kind in the world, said it was medically necessary. This article is not about Advantage insurance but is a look into how insurance companies operate to keep costs low, which is what they do in Advantage plans. https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis

 

[EMNofSeattle]

Make it mandatory for everyone (all US citizens, rich, poor famous regardless of nationality or political office) to receive the same healthcare through a single payer and I will be 100% on board with it. What I suspect will happen is the rich, famous or people in public office will receive the best of the health care while the rest of us get in line and get what's left over.

When I was a sailor in the USN I was onboard a small ship. But we all ate really good. One reason because we all got the same food. E1 to the Captain.

Why? I don’t want to go to the same health care facilities as the underclass.

 

[Hamish Howl]

Why? I don’t want to go to the same health care facilities as the underclass.

HAHAHAHAHAHAHAHAHAHAHA!!

Of course you don't. You're a tycoon, right?

 

[ALiberalModerate]

You have listed every reason why Canada nationalized health care in the late 1960's'

Profit is good when there is competition. The health field in most cases are private and need profit to survive. However, with health care, like dentistry, it's easy to cheat, advise new meds (for a kick back) and providing services that are marginally needed but profitable. And even with competition, the prices rise as doctors and medical clinics consider posted rates a "suggestion".

I bet if you ask enough people in one day, you will hear a half a dozen horror stories.

There are numerous problems with ensuring competition in healthcare, one of the main ones though is that only about half of healthcare markets in the United States are big enough to even have a competitive market.

The other half are monopolies where one health system controls the entire local market.

 

[ALiberalModerate]

Interesting. The other week you were bragging to me how Medicare costs have been falling relative to earlier projections.

So, that coincided with an expansion of the portion of the Medicare populace that was choosing a more privatized option?

Huh. Well Whattya know

If the government picked up the tab for it, wouldn't you look at private options?

 

[Greenbeard]

So, that coincided with an expansion of the portion of the Medicare populace that was choosing a more privatized option?

Huh. Well Whattya know

Unfortunately it still costs the taxpayers more if a beneficiary chooses Medicare Advantage over traditional Medicare, as it always has.

If the government picked up the tab for it, wouldn't you look at private options?

It’s really stunning how much more that private option costs the taxpayers than traditional Medicare:

According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare.2 Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

 

[ttwtt78640]

It’s really stunning how much more that private option costs the taxpayers than traditional Medicare:

My girlfriend and I both have WellCare ’give back’ Medicare Advantage plans which pay us each $95/month. That is with no annual deductibles and minimal (rare?) co-pay amounts.

I have to pay a $75/year penalty for not having had Part D coverage for one year, but my girlfriend’s $150/year penalty for not having had Part D coverage for two years has been waived due to her having a ($1K/month) lower Social Security income level than I have.

I have never seen WellCare mentioned as having had any trouble with over-billing Medicare for their Medicare Advantage plan services. The only ‘catch’ seems to be having to use ‘in network’ care providers.

 

[PeacefulWarrior]

That was easy. Too bad we won't move anything for the next two years, not with the clown show in the House.

It wouldn't happen even without that clown show in the House.

 

[PeacefulWarrior]

Why? I don’t want to go to the same health care facilities as the underclass.

Dont want to be with your own kind?

 

[ALiberalModerate]

It’s really stunning how much more that private option costs the taxpayers than traditional Medicare:

True, but it’s often a better deal for recipients. That said, I think what some people don’t seem to get is seniors would be uninsurable without Medicare or subsidies that are more expensive than Medicare. There is no privatized option that saves taxpayer money. Medicare is expensive because healthcare for seniors is expensive. If you want a cheaper Medicare program, then you have to go after the providers. The insurers are maybe 5% of the problem. Most of it is the providers.

 

[aociswundumho]

True, but it’s often a better deal for recipients. That said, I think what some people don’t seem to get is seniors would be uninsurable without Medicare or subsidies that are more expensive than Medicare. There is no privatized option that saves taxpayer money. Medicare is expensive because healthcare for seniors is expensive. If you want a cheaper Medicare program, then you have to go after the providers. The insurers are maybe 5% of the problem. Most of it is the providers.

All of it is the providers, and the providers are untouchable.

 

[Greenbeard]

MedPAC, which advises Congress on Medicare policy, released one of its two annual reports to Congress this month. It spends a whole chapter digging in on Medicare Advantage, concluding that the privatized component of Medicare is not only raising costs for taxpayers but is actually driving up premiums for Medicare enrollees.

The Commission remains concerned that the benefits from MA’s lower cost relative to FFS spending are shared exclusively by the companies sponsoring MA plans (in the form of increased enrollment and revenues) and MA enrollees (in extra benefits). The taxpayers and FFS Medicare beneficiaries who help fund the MA program through Part B premiums do not realize any savings from MA plan efficiencies. Instead, Part B premiums are higher for all beneficiaries than they otherwise would be. Further, Medicare spends 6 percent more for MA enrollees than it would spend if those beneficiaries were enrolled in FFS Medicare, a difference that translates into a projected $27 billion in 2023. This amount would be even larger if the favorable selection of beneficiaries in MA plans were taken into account because beneficiaries who choose to enroll in an MA plan tend to be more profitable than beneficiaries who remain in FFS Medicare.

Not great!