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Health plans put the squeeze on Medicare Advantage

Medicare Advantage billing is getting, shall we say, unscrupulous, per a recent article from Bloomberg. When will it end?

For health insurers, the Medicare Advantage (MA) cup is definitely not half empty. In fact, the cups runneth over as insurance companies seem to squeeze as much as they can from the federal government.

And Bloomberg is calling them out. The publication recently covered a trend we’re all too familiar with – private insurers playing fast and loose with their Medicare Advantage billing.

Backing up their piece is Teresa Ross, an early whistleblower who filed a suit against Group Health Cooperative, now part of Kaiser Permanente, back in 2012. Her objection: that the insurer was identifying new diagnoses for patients, which weren’t necessarily true, and was thus racking in millions of dollars. Ross’ pushback only got her company-enforced sessions with a psychologist (yes, really) and pushed out of meetings.

Since then, other whistleblowers have come forward and the Department of Justice has reviewed or intervened in Medicare billing cases involving United Healthcare, Cigna, and Anthem.

If this topic sounds familiar, it should. In the fall of 2021, an exclusive in the Wall Street Journal found controversial billing practices were seriously spiking payor profits.

A quick MA recap: Medicare is the term for health benefits provided to individuals 65 years and older, and those with certain health conditions. It’s operated by the federal government, which contracts with private health plans to actually oversee benefits and claims.

Ostensibly, these plans are supposed to be better and more efficient than a government enterprise. We can’t imagine they are intended to drive costs up, but the article outlines ways that health plans and a “cottage industry of vendors” have developed ways to maximize payments. The health plans deny all wrongdoing, but tactics include including mining patient charts and prodding doctors to review potentially missed diagnoses.

So, is the juice worth the squeeze? Must be:

Per an article in Fierce Healthcare, a new study from The Chartis Group found that for-profit health plans are having a major come-up as enrollment for Medicare Advantage plans are growing (2.3 million beneficiaries for the 2022 coverage year). And 85% of those new enrollments went to Big Insurers, including United, Centene, and Aetna.

Chartis states: “11 states now have half or more of their eligible populations enrolled in a Medicare Advantage product, up from only three states last year.”

We can only imagine another number may start to swell: health insurer billing cases. Unfortunately, according to Bloomberg, these current cases could take years to resolve. But we may not have that much time.  Medicare’s Trust – from which Medicare Advantage plans are paid – is projected to be depleted by 2026, leading to major deficits.

Where will the juice be then?

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