Bloomberg News reports on allegations that several major health insurance companies are defrauding the federal government, inappropriately billing Medicare. A host of whistleblowers have compelling stories to tell. And, the Justice Department is investigating Anthem, UnitedHealth and Cigna, among other insurers offering Medicare Advantage plans.
One whistleblower tried to help her boss at the insurance company understand that the billing wasn’t correct. Patients were being given diagnoses that were fraudulent, in her view. Instead, the company decided she suffered from a mental illness.
The company was “upcoding,” adding additional diagnoses to their enrollees’ records. But, by alleging the upcoding, he whistleblower was told she wasn’t a “team player.” She was objecting to activities that were delivering more revenues to the company. She ended up leaving the company. Reports indicate that most, if not all, insurers are playing by a set of rules that make their members look sicker in order to generate more income from Medicare.
With nearly half of the Medicare population in Medicare Advantage plans now, some experts say that Medicare will overpay these insurers hundreds of billions of dollars over the next decade. These overpayments are driving up premiums for people in traditional Medicare, eating into the Medicare Trust Fund and threatening Medicare’s solvency. So far, neither Congress nor the administration has been willing to stop them.
Medicare Advantage is politically complicated. The Republicans in Congress, who generally do not support government-run Medicare, praise Medicare Advantage as “innovative,” ignoring the data that shows 1. Whatever its innovations, Medicare Advantage costs more than traditional Medicare; 2. Medicare Advantage is not meeting the needs of many people with complex and costly conditions; they are switching to traditional Medicare at high rates; and, 3. widespread and persistent violations of their contractual obligations.
Most members of Congress, for their part, are not focused on the value of traditional Medicare for providing millions of their constituents with easy access to quality care, for understanding what’s working and not working in our health care system, and for driving system improvements. Of course, it is also far more cost-effective than Medicare Advantage.
Here’s more from Just Care:
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- One in four Medicare Advantage plans engage in misleading marketing
- Medicare Advantage benefits: Appearances v. reality
- Don’t judge a Medicare Advantage plan by its stars
- Well-kept secrets of Medicare Advantage plans
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