Medicare Advantage continues to steal from taxpayers

[eridani]

http://www.publicintegrity.org/2014/08/07/15216/how-medicare-advantage-plans-code-cash

A new federal study shows that many Medicare Advantage health plans routinely overbill the government for treating elderly patients — and have gotten away with doing it for years.

Analyzing government data never before made public, Department of Health and Human Services researchers found that many plans exaggerate how sick their patients are and how much they cost to treat. Medicare expects to pay the privately run plans — an alternative to traditional Medicare — some $160 billion this year.

The HHS study does not directly accuse any insurers of wrongdoing or name specific plans that were scrutinized. But the researchers offer the most comprehensive evidence to date that suspect billing practices have been common across much of the Medicare Advantage industry and are likely to get worse unless officials crack down.

Medicare pays the Advantage health plans higher rates for sicker patients and less for healthy people using a complex formula called a “risk score.” But the HHS study spells out several ways health plans have inflated those scores, from reporting implausibly high levels of medical conditions such as alcohol or drug dependence to billing for an inordinately high number of patients with complications of diabetes.

Despite its broad implications for Medicare spending, the study by HHS researchers Richard Kronick and W. Pete Welch has attracted scant notice in Washington. It was quietly posted late last month on an online research site run by the Centers for Medicare and Medicaid Services, part of HHS.

Kronick directs the HHS Agency for Healthcare Research and Quality, whose mission is to improve health care delivery. Welch works for the HHS Office of the Assistant Secretary for Planning and Evaluation.

Comment by Don McCanne of PNHP: We have discussed before the ways in which the private Medicare Advantage (MA) plans have been cheating the taxpayers, including cheating the beneficiaries in the traditional Medicare program who are paying higher premiums to support these private MA plans. Today’s message is especially significant since it cites a detailed 19 page report from the director of AHRQ and his colleague - a report which further confirms the private insurers’ distortion of Hierarchical Condition Categories (HCC) to receive extra risk adjustment payments based on upcoding that reports their patients as being more ill than they actually are (i.e., they pad the diagnoses).

The history of Medicare Advantage is that of a steady string of abuses. The program began with overpayments of about 14 percent over the cost of caring for Medicare patients in the traditional program. That overpayment was a deliberate ploy of Congress to give the private plans a competitive market advantage in an effort to privatize Medicare. The plans then selectively enrolled healthier, less expensive patients through deceptive marketing practices. When an effort to correct this favorable selection was made through risk adjustment using Hierarchical Condition Categories, the insurers then padded the diagnoses, as mentioned above. Further, since the Affordable Care Act included adjustments to correct the overpayments, the insurance industry heavily lobbied Congress and the Obama Administration to use three years of accounting gimmicks to reduce the impact of these adjustments. Cheat, cheat, cheat.

What can we expect now? Richard Kronick and W. Pete Welch are reserved in their language when they state, in a footnote, “Some would expect that MA plans will react to the 2013 and 2014 model changes by finding other HCCs on which to focus their efforts, and the success of coding intensity efforts may well increase in the future.”

I’ll be more frank. These crooks will continue to cheat the American taxpayers. They will surely use other HCCs to upcode their patients, until that door is finally slammed shut. What then? The private insurers continually tout to their shareholders the importance of “innovation” in health care coverage. They will always be able to find new and more effective ways to cheat us.

[Hoyt]

1. Truthfully, traditional Medicare ain't treating patients well. Co-pays, no out-of-pocket cap,

gotta pay separately for drug coverage, supplemental coverage, etc. Decent supplemental and drug coverage will cost a Medicare beneficiary over $200 monthly in addition to the Part B premium (so over $300 per month).

Roughly 30% of Medicare beneficiaries have voluntarily elected to signup with Medicare Advantage plans because they think it's a better deal and/or it's all they can afford.

Before bashing these plans, the government ought to improve traditional Medicare, but they won't anytime soon.

No, I don't work for Advantage plans, nor am I saying they are better than what Medicare beneficiaries could/should have.

I am saying, there are a very good alternative for Medicare beneficiaries who can't afford a decent supplement to traditional Medicare and drug coverage, but are not poor enough to qualify for Medicaid and Medicare.

As far as "innovation in health care" -- we darn sure need some.

[eridani]

2. So what do Medicare Advantage plans do to deserve getting paid an extra 14%

--over tradtional Medicare plans.

[msongs]

3. donate bribes...errr campaign contributions to dems and repubs alike who allow this? nt

[eridani]

4. I'm shocked! SHOCKED!!! that you would say such a cruel thing!

[Hoyt]

6. You don't think your doctor, hospital, chiropractor, etc., is ontributing either directly and/or

through their medical society PACs. You really need to take a hard look at what is going on, my friend.

Physicians and hospitals determine who gets elected in a lot of areas. And most of them are as conservative as Ron Paul and Rand Paul. They had a lot to do with how the ACA came out too because most don't want single payer.

[Hoyt]

5. Most importantly, they cap the out-of-pocket costs beneficiaries are subject to. Next, they provide

services traditional Medicare does not. Next, they provide supplemental coverage as part of their plan. Next, they provide some drug coverage, traditional Medicare does not. Perhaps most importantly, they provide some coordination of care that traditional Medicare does not.

For example, if I go traditional Medicare, I will pay $110 to the government per month for Part B coverage (I'll also pay that if I select Advantage).

Next, if I want supplemental coverage to pay coinsurance, deductibles, drug, provide a cap on out-of-pocket, perhaps a few more days of nursing home care in addition to the limited amount Medicare covers before you qualify for Medicaid after becoming essentially destitute, etc., that'll cost me at least an additional $200.

Again, most importantly if I go to an Advantage plan like non-profit Kaiser, I'm going to get coordination of care among health care providers. Or, I can take traditional Medicare, hope I can find providers who will accept me. Then, I can hope all the providers I select actually work with each -- like read/review what the other one is doing when you are in the hospital or being treated for a serious chronic condition. And, I get all that hassle and have to pay $200 or so a month extra to get supplemental and drug coverage.

Also, I can compare the quality ratings of Medicare Advantage plans. I can't do that easily when I'm choosing from thousands of doctors, hospitals, diagnostic test providers, DME providers, etc., many of whom are in it only for the money.

Truthfully, if the government is paying 14% more, it's worth it for the reasons above. But, I don't believe they are paying that much more because the law stipulates they pay these plans a few percentage points more that traditional Medicare would have paid (they handle registration, coordination of care, quality reporting, pay claims, etc.). If the plans are inflating the severity of the patient population, that's an easy fix.

The fact that 30% of beneficiaries are selecting Advantage plans tells me they like it. It's relatively new, a lot of people don't know it exists, etc. -- so they must like it. The ACA includes incentives for providers to form what are essentially Medicare Advantage plans. Until they do so, I think smart Medicare beneficiaries know what they are getting.

[Cleita]

8. Lucky you if you can get Kaiser because most providers won't take advantage plans.

Most doctors who do take it in my area are not very good doctors and can't get other patients.

[Hoyt]

12. How do you determine who is a good doc -- they have a pretty office, drive a nice car, have certain

clientele, etc.

I'm sorry, I'll take a doc who'll see Medicaid patients, Advantage patients, etc., any day over one that only accepts the high paying clients.

[Cleita]

7. I'm all for stopping it and using the money to fully fund Medicare so we old farts don't

have to buy supplemental insurance. This is how advantage plans get people to sign off their Medicare coverage by promising them full coverage but then doing the usual insurance stuff of trying to deny coverage, stiff providers and cheat the American taxpayer.

[Hoyt]

9. Problem is, the government isn't going to take that money and "fully fund Medicare."

If it's such a bad deal, why do 30% of beneficiaries stick with it. They can go back to traditional Medicare, but choose not to. Probably because is saves them substantial money and takes the burden off them for finding providers.

The number of beneficiaries choosing Advantage plans have been increasing around 1.3 million for the last several years.

The nice thing is, if you don't want to go under an Advantage plan, you don't have to.

[Cleita]

10. Advantage programs, which privatize a single payer system, suck.

The right Congress can change it and frankly my personal experience with an advantage program cost my husband and me $10,000 because the insurance company could deny us coverage traditional Medicare did cover eventually. My husband was on Medicare for thirteen years and I have been on it for ten. What sucks is the privatized supplemental insurance and pill program. That needs to change as it's costing more than it should for old people on SS. The right Congress can do it and it will save money. The poor, poor insurance companies will be left out in the cold, but I'm sure they will find other ways of preying on victims with their parasite product.

[Hoyt]

11. The "right Congress" can do a lot of things. But, "right Congress" ain't close despite our efforts.

You are right that the supplemental and drug programs are outrageous. That's why more and more folks are forgoing paying them $200 out-of-pocket a month and signing up for Advantage Plans to provide some of that.

Actually, the insurance companies aren't out in the cold with traditional Medicare -- they pay the claims, enroll providers, make coverage decisions, answer your appeals, etc. The government doesn't do much more than they do with Advantage Plans.

[Cleita]

16. If you have to travel interstate like my DH and I did, the MA's will mostly not

pay until your primary care signs off of it. If you, like me who had Kaiser, when I was working in Idaho, where there is no Kaiser, I had to pay out of pocket cuz, I had no Medicare coverage there. With traditional Medicare, you are covered no matter which state you are in. MA only pays for emergencies and only if you call first for authorization. I had to call for an ambulance for my husband, who was having a stroke, from a pay phone alongside a Hwy. Needless to say, I couldn't call their bureaucratic office first for permission. That's how we got stuck with a $10,000 Bill.

Not only that, when we returned home, my DH's primary care stopped taking the plan for non-payment and no other doctor in the area was either. This was Blue Cross that my husband had. I had the Kaiser. It was basically another useless POS from our insurance industry, but good for them to put their greedy paws into the Medicare fund.

[Hoyt]

17. Very sorry you had such a bad experience. You can have it with traditional Medicare too.

I'm also glad you can afford the extra $200 or so a month for a decent supplement in drug coverage. A lot of folks can't.

Most Advantage Plans pay the same as traditional Medicare, some even pay more.

Nowadays, most plans will pay out-of-network for emergencies and I know of none who require you to get prior approval during an emergency. They do require you to call as soon as practicable and that makes sense. Ever been to a family physician with a complex clinical lab, CT/MRI scanner, nuclear lab, etc., in his/her office. Not surprisingly, the utilization goes up dramatically when the doc profits from every tic on his order sheet.

[Cleita]

18. I really can't afford it because I'm only on SS but I do without other

things to afford it because it gives me a good sense of health security I've never had before and it has always paid up and come through for me.

[SammyWinstonJack]

13. +1!

[meow2u3]

14. The real reason for Medicare Advantage

is for health insurance companies to take Advantage of people on Medicare.

[Hoyt]

15. Yeah, those 15.5 million that choose it year-after-year are all suckers.

[eridani]

19. Yes, they are. With health care you don't find out that you are screwn until

--you get expensively sick, and that only happens to 15% of the population in all age demographics.

[Hoyt]

20. Get expensively sick on traditional Medicare and you better have an expensive supplemental policy.

Otherwise, you will loose everything and end up on Medicaid , if lucky.