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Who will fight the insatiable Medicare Advantage ‘cash monster’?

Overdiagnosing, overbilling, and overpayments – oh my! These are just some of the tactics Medicare Advantage plans are using to waste federal dollars — and patients’ time.

According to a recent article in the New York Times, by next year, half of Medicare beneficiaries will have a privately operated Medicare Advantage (MA) plan.

Seems innocuous enough. But wait, there’s more. Nearly all large MA insurers — the ones in charge of said coverage — have been accused of fraud.

In case you need a refresher, Medicare is the federal health program that covers most Americans 65 and older and some younger individuals with certain health conditions. Over the last decade, more and more Medicare coverage has been provided through MA plans, through which the federal government pays a private company to manage the care for beneficiaries.

This approach was designed by the federal government to “encourage health insurers to find innovative ways to provide better care at lower cost,” says the Times.

Seems reasonable . . . until you look at the lawsuits.

  • UnitedHealthcare? Accused of fraud by a whistleblower, accused of fraud by the U.S. government, and accused of overbilling by the Inspector General. (The big three!)
  • Cigna? The same.
  • Humana? Accused of fraud by a whistleblower, and of overbilling by the Inspector General.
  • Elevance Health (formerly known as Anthem)? Accused of fraud by the U.S. government and overbilling by the Inspector General.

What’s going through your head is likely the same thing that’s going through ours, which is: Just how are these insurance companies continuing to pull the wool over the government’s eyes?

One tactic: Overdiagnosing. Get this. Payors, who never lay a finger on patients, and have no firsthand knowledge of their diagnoses, are going back through patient records to “document” more medical conditions than the physician . . . who actually saw the patient.

That’s because the government pays MA insurers a fixed rate for each plan enrollee. The sicker that person is, the higher the rate the insurer gets paid. And that’s the part where insurers start rubbing their hands together – or so we imagine.

“The insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits,” the article reports.

Another tactic: Inflated billing.

“Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits,” says the Times.

Need we remind you that these are the very same insurers who deny claims and slash coverage when it’s their bankroll footing the bill instead of the federal program. In other words, they aren’t in the business of covering care efficiently. They’re in the business of making as much profit as possible from the U.S. healthcare system — which, depending on the situation — could mean pushing patients to get more care, or constricting access for less care.

Either way, with more and more Americans covered in private MA plans every year, it begs the question – are we actually getting any value out of this arrangement?

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