The HHS Office of the Inspector General (OIG) released yet another scathing report on Medicare Advantage plans, the private health plans that contract with the Centers for Medicare and Medicaid Services to offer people Medicare benefits. This time, instead of focusing on widespread and inappropriate delays and denials of care, the OIG raises concerns about Medicare Advantage plans bilking the federal government of billions of taxpayer dollars. It also raises concerns about the lack of oversight of Medicare Advantage plans.
The federal government compensates Medicare Advantage plans with higher rates for members with diagnoses that suggest they would benefit from care coordination. To take advantage of these higher payments, Medicare Advantage plans send health risk assessors to the homes of their members; the goal is that more of their members are diagnosed with a condition for which the government will pay them more. The Medicare Advantage plans do not wait on these members’ treating physicians to identify these diagnoses; they assume they can bill CMS a higher rate if they hire someone to assess their members.
Of course, the diagnoses that lead to higher payments should also lead Medicare Advantage plans to provide more care for these members. But, the OIG found that many Medicare Advantage plans got higher payments for members who never received any care coordination or other follow-up care from them. Rather, it found that the Medicare Advantage plans got $2.6 billion as a result of these self-serving health risk assessments.
The Centers for Medicare and Medicaid Services, for its part, did not concur with the majority of OIG recommendations to address potentially hundreds of millions in overpayments to Medicare Advantage plans. CMS is prepared to do some oversight of Medicare Advantage plans. But, it does not feel the need to require Medicare Advantage plans “to implement best practices to ensure care coordination for health-risk assessments.” Nor does it see a need to rethink whether it is appropriate to allow Medicare Advantage plans to do in-home risk assessments for members and to pay them more for these members, even when these members do not use much, if any, health care.
Here’s more from Just Care:
- Ten ways Medicare Advantage plans differ from traditional Medicare
- The wrong choice of Medicare Advantage plan could kill you
- Senators ask Medicare agency why it is not holding Medicare Advantage plans accountable for violating their contractual obligations
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- Traditional Medicare offers better home care benefits than Medicare Advantage
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