Government watchdogs attack Medicare Advantage for denial of care and overcharging

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients life-saving medical care while overburdening the government with billions of dollars each year, government watchdogs told a panel Tuesday. Bedroom.

Witnesses sharply criticized the fast-growing health plans during a hearing by the Energy and Commerce Subcommittee on Oversight and Investigations. They cited a slew of critical audits and other reports describing plans denying access to healthcare, especially those with high rates of patients who were opted out in their last year of life as they were probably in poor health and needed more services.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors shouldn’t be “forced to jump many hurdles” to access health care.

The watchdogs have also recommended placing limits on in-home “health assessments”, arguing that such visits can artificially inflate payments to schemes without providing patients with proper care. They also called on the Centers for Medicare & Medicaid Services, or CMS, to revive a stalled audit program that is more than a decade behind in recover billions in alleged overpayments to health plans, which are mostly handled by private insurance companies.

Regarding denial of treatment, Erin Bliss, assistant inspector general for the Department of Health and Human Services, said a Medicare Advantage plan denied a request for a CT scan, or computed tomography, that “was medically necessary to rule out a diagnosis potentially fatal (aneurysm).

The health plan required patients to first undergo an X-ray to prove that a CT scan was necessary.

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in Original Medicare.”

Leslie Gordon of the Government Accountability Office, the oversight arm of Congress, said seniors in their last year of life dropped out of Medicare Advantage plans twice as often as other patients leaving the plans.

Rep. Frank Pallone Jr. (DN.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to learn that some patients are facing “undue barriers” to get care.

Under the original health insurance, patients can see any doctor they choose, although they may need to purchase an add-on policy to cover gaps in coverage.

Medicare Advantage plans accept a flat fee from the government to cover a person’s health care. The plans can provide additional benefits, such as dental care, and cost patients less, although they limit the choice of medical providers as a trade-off.

These trade-offs aside, Medicare Advantage is clearly proving attractive to consumers. Registration more than doubled over the past decade, reaching nearly 27 million people in 2021. That’s nearly half of all people on Medicare, a trend that many experts predict will accelerate as legions of baby boomers retire.

James Mathews, who heads the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could reduce costs and improve medical care, but “falls short of that potential” despite its broad acceptance among old people.

Notably absent from the hearing’s witness list was someone from CMS, which runs the $350 billion-a-year program. The agency accepted a pass even though the committee The invited Republicans CMS Administrator Chiquita Brooks-LaSure will testify. Rep. Cathy Rodgers (R-Wash.) said she was “disappointed” CMS launched, calling it a “missed opportunity.”

CMS did not respond to a request for comment in time for publication.

AHIP, which represents the health insurance industry, released a statement who said Medicare Advantage plans “provide better service, better access to care, and better value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

During Tuesday’s hearing, Republicans and Democrats stressed the need to improve the program while strongly supporting it. Still, the detail and degree of criticism was unusual.

More typically, hundreds of members of Congress argue against cuts to Medicare Advantage and cite its growing popularity.

At the hearing, the gendarmes sharply criticized the home visits, which were controversial for years. Since Medicare Advantage pays higher rates for sicker patients, health plans can take advantage of patients appearing sicker on paper than they actually are. Bliss said Medicare paid $2.6 billion in 2017 for diagnoses supported by health assessments alone; she said 3.5 million members had no records showing they had received care for health conditions diagnosed during these health assessment visits.

Although CMS chose not to appear at the hearing, officials clearly knew years ago some health plans abused the payment system to increase their profits but for years the program was run like what a CMS manager called an “honor system”.

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation”, or RADV. Health plans were instructed to send CMS medical records that documented each patient’s health status and return payments when they could not.

The results were disastrous, showing that 35 of the 37 plans selected for review had been overpaid, sometimes by several thousand dollars per patient. Common conditions that were overestimated or unverifiable ranged from diabetes with chronic complications to major depression.

Yet CMS still hasn’t completed audits dating back to 2011, through which officials expected to recover more than $600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to require the agency to publish audits from 2011, 2012 and 2013 – the audits, according to the agency, are still not complete. CMS is expected to publish the audits later this year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.

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