The Centers for Medicare and Medicaid Services (CMS), the agency charged with overseeing Medicare, recently released a series of proposed rules intended to limit harmful behavior in Medicare Advantage. They aim to curtail misleading marketing as well as to eliminate barriers to care. Many of the rules seem good in theory but, even if finalized, unless CMS enforces them and applies meaningful penalties for violating them, it is hard to imagine that they will do much good.
For years, Medicare Advantage plans have been violating rules. They have not covered medically necessary services covered in traditional Medicare, as required; they have overcharged the government for their services; they have failed to disclose complete and accurate data that would allow oversight of the quality of care they deliver; they have not maintained accurate provider directories and more. The HHS Office of the Inspector General, the Government Accountability Office and the Medicare Payment Advisory Commission, among others, have called out these issues and urged CMS to address them through new policies, greater oversight, and penalties that are meaningful. CMS has done little to call out the bad Medicare Advantage actors and penalize them appropriately, putting people enrolled in Medicare Advantage plans at risk.
For example, for more than ten years, Medicare Advantage plans have overcharged the government billions of dollars a year, with projections that the overcharges will total more than $600 billion in the next nine years. And, MA plans have not released the patient data they are required to disclose, Yet, CMS has done little if anything to address their malfeasances and bad acts, endangering the lives of enrollees and draining the Medicare Trust Fund.
You can review the CMS enforcement actions over the last decade here. Last month, CMS “punished” Elevance, a Medicare Advantage plan, “for failing to meet its primary responsibility to provide Medicare enrollees with medical services and prescription drug benefits in accordance with Medicare requirements.” CMS found that Elevance overcharged its enrollees. The penalty? $38,512.
CMS also punished Humana $131,660. “Auditors found that Humana overcharged enrollees for Part D medications and Part C services. Humana’s failures adversely affected (or had the substantial likelihood of adversely affecting) enrollees because they may have experienced increased out-of-pocket costs.”
Auditors found that “in 2019 Kaiser failed to reprocess prescription drug claims in accordance with enrollee’s LIS levels within 45 days of the receiving complete information regarding the enrollees LIS status. As a result, enrollees were over charged for Part D drugs at the point of sale and Kaiser then failed to ensure refunds were provided to enrollees who overpaid.” The penalty? $27.260.
Where are the incentives for insurers offering Medicare Advantage plans to do right by Medicare? Where’s the requisite oversight? Where’s the punishment for the wrongful behavior? People go to jail for not paying their medical bills; they go to jail for years for defrauding the government. It appears that the MA plans can do major harm to Medicare, with impunity.
When will the government stop simply talking the talk and walk the walk?
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- CMS overpays Medicare Advantage plans and lets them keep the extra billions
- Profiteers turn hospice into a $22 billion industry
- Medicare Advantage plans fail to release data required for oversight
- The high costs of Medicare Advantage and how to address them
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