Medicare Advantage (MA) plans – the privatized alternative to traditional Medicare – are coming under growing scrutiny for a number of questionable practices that undermine patient care and overcharge taxpayers.  This week, the Washington Post reported about a whistle-blower from a Medicare Advantage outfit in California who is working with federal investigators looking at alleged, widespread malfeasance on the part of MA plans. According to the Post:

“The Justice Department is pursuing civil lawsuits against multiple companies that participate in the privatized system, from huge insurers to prestigious nonprofit hospital systems, alleging they have cheated the system for unfair profit.” – Washington Post, 6/5/22

Investigators are probing allegations that some MA plans are billing the Medicare program for patient care based on “outdated or irrelevant” diagnoses, in order to make more money.  These include conditions like heart disease, depression, obesity, and cancer that patients had already surmounted — or that they never had in the first place.  Critics say that in addition to overcharging the government for care for these patients, MA plans billing for outdated or false diagnoses could stigmatize patients “who were improperly deemed obese, malnourished or mentally ill.”

“The point of larding the medical records with outdated and irrelevant diagnoses such as cancer and stroke — often without the knowledge of the patients themselves — was not providing better care, according to a lawsuit from the Justice Department; (it was to make higher profits).” – Washington Post, 6/5/22

Some Medicare Advantage plans have long been accused of “upcoding,” which means “submitting bills for more severe and expensive diagnoses or procedures than (were) diagnosed or performed,” according to the National Center for Biotechnology Information. Plain and simple, this is a form of fraud. The victim is the Medicare program — and the workers, taxpayers, and enrollees who fund it.

The irony is that Medicare Advantage plans, which began during the George W. Bush administration, were supposed to save the Medicare program money.  Instead, these privately-run, for-profit plans are “costing taxpayers more money to run than traditional fee-for-service Medicare,” notes the Washington Post.  

According to MedPAC, a government watchdog panel, the federal government incurred $12 billion in “excess payments” to Medicare Advantage plans in 2020.  MedPAC projected the figure will swell to $16 billion next year.

Meanwhile, the HHS Inspector General’s office issued a report in April, showing that some MA plans are denying “medically necessary” claims and pre-authorizations that should be covered under Medicare rules. Again, the motive seems to be squeezing more money out of the federal government at the expense of patient care.

“The Inspector General’s report explains that because the Centers for Medicare and Medicaid Services (CMS) pays Medicare Advantage plans a flat fee regardless of the amount they spend on care, they have a ‘potential incentive…to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.’” – Common Dreams, 6/8/22

Despite the mounting evidence of wrongdoing on the part of some MA plans, Medicare Advantage continues to grow in popularity. MA is on the brink of capturing more than half of the Medicare market, which up to now has been dominated by traditional Medicare. This is thanks, in so small part, to the torrent of television ads featuring celebrity pitchmen, promising lower premiums and free benefits like gym memberships and rides to the doctor’s office.

The ads, of course, do not mention that MA plans offer limited networks of providers – or that medically necessary claims and pre-approvals may be denied so the plans can make more money. Nor do Joe Namath and Jimmy Walker tell viewers that some plans are over-billing the government for false or outdated diagnoses, and without patients’ knowledge.

Instead of being held truly accountable, Medicare Advantage plans are being rewarded with an 8.5% revenue increase from the federal government for 2023. Since this privatized version of Medicare was created, for-profit companies have gained increasing influence in the care of one of our most vulnerable populations – the elderly. It is welcome news that the Justice Department and HHS Inspector General’s office are intensifying their scrutiny of Medicare Advantage.  At stake is nothing less than billions in taxpayer dollars and the wellbeing of millions of America’s seniors.