For no good reason, our federal government pays Medicare Advantage plans a set amount per enrollee regardless of the amount these health plans spend on care and regardless of whether they inappropriately delay and deny care and deny payments to providers. Moreover, our government pays the insurance companties extra if they add diagnosis codes to patient records, even when patients have not received treatment for those diagnoses. Now, FierceHealthcare reports that Humana is challenging the government’s new standards for getting some of the overpayments back.
It seems reasonable that if the government found that it was overpaying Medicare Advantage plans, it could get its money–taxpayer dollars–back. Not so. It turns out that the government’s payment system not only overpays Medicare Advantage plans collectively tens of billions of dollars a year, but it struggles to recoup any of these overpayments.
Humana’s recent lawsuit challenges the government’s new Medicare Advantage auditing standards. It argues in its lawsuit against the Centers for Medicare and Medicaid Services (CMS), which administers Medicare, that if the government recouped overpayments, Medicare Advantage plans and their enrollees could be harmed.
Put simply, Humana likes the overpayments and wants to keep them. As it is, the government’s new standards for recouping overpayments have an extremely short look-back period, to 2018. So, billions in government overpayments through 2017–our Medicare dollars– already belong to the health insurers.
Humana’s legal challenge centers on the fact that the government’s final rule regarding its ability to recoup overpayments to Medicare Advantage plans does not allow the Medicare Advantage plans to keep any of the overpayments they receive. “CMS abused its discretion by concluding that retroactive application of the final rule is necessary to comply with statutory requirements,” says Humana.
If Humana prevails, it is yet another reason why the Medicare Advantage payment system needs an overhaul. It is wasteful and inefficient.
Here’s more from Just Care:
- What happens when Medicare Advantage overpayments end?
- CMS overpays Medicare Advantage plans and lets them keep the extra billions
- Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care
- Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees
- Ohio and Virginia hospitals warn residents they could stop taking Medicare Advantage patients
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