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Breaking news for the DHHS…but not for us

An exclusive report in a September 22 article in the Wall Street Journal explains that Medicare insurers—private companies managing care for seniors on behalf of the federal government—haven't been totally above board.

Finally, at (very) long last, the Department of Health and Human Services (DHHS) is putting the many pieces of Medicare fraud together.

An exclusive report in the Wall Street Journal explains that Medicare insurersprivate companies managing care for seniors on behalf of the federal governmenthaven’t been totally above board. Color us shocked.

The article shares, “Medicare insurers drew $9.2 billion in federal payments in one year through controversial billing practices, with 20 companies benefiting disproportionately and together accounting for more than half of the total.”

And as the Office of Inspector General at DHHS was digging in (what took you so long?), they concluded that “insurers might be gaming the process to improperly boost federal payments.”

You. Don’t. Say.

Well, we’ve said it. A couple times, actually.

Exhibits A, B and C:
A private health plan mismanaging government funds? Color us shocked.
Cigna accused of fraudulently overbilling Medicare Advantage plans.
D.C. Circuit overruling means the game is afoot!

You get the point.

The WSJ report outlines some issues with the insurers’ approaches in detailing members’ diagnoses. Because payments from the federal government are tied to member health status, there’s an incentive to up-code (i.e., report health needs were more severe than they were) and overcharge.

And it seems one company, among the 20, stands out from the rest. The article states: “Among the 20 companies flagged in the report, the investigators found that one received approximately 40% of the questionable payments, or $3.7 billion, while enrolling only 22% of Medicare Advantage customers. The report didn’t name the company.”

We wait with bated breath… but federal data compiled by analysts at BMO Capital Markets found that enrollment share closely matched that of industry giantUnitedHealth Group Inc.’s during the period covered in the report.

Oh, you mean the same United that recently had plans shut down by CMS?
Or the one that’s accused of penny-pinching pediatricians?
Or the one that sued so it didn’t have to pay back overpayments?

We promise not to say, “I told you so.”

Look, all sarcasm aside, we’re glad to see these investigations, but where are the consequences? If it’s like any of the other cases we cover, insurance companies might get hit with some fines. But if we’ve learned anything, it’s that slaps on the wrist don’t lead to much when your profits are in the billions.

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