In a June 28, 2022 US House Energy and Commerce Oversight and Investigations Subcommittee hearing, representatives of the HHS Office of the Inspector General (OIG), Government Accountability Office (GAO) and Medicare Payment Advisory Commission (MedPac) told Congress in no uncertain terms that Medicare Advantage–Medicare Part C, which is administered through private health insurers–needs fixing. Medicare Advantage (MA) inappropriately restricts access to care that traditional Medicare covers.
Subcommittee members said that they believe it is of utmost importance that Medicare Advantage delivers people the Medicare benefits they need. Nearly 27 million older adults and people with disabilities are now enrolled in MA, costing taxpayers $350 billion a year. But, “some Medicare Advantage plans are not acting responsibly.”
People in Medicare Advantage are entitled to the same services as people in traditional Medicare, but they are not always receiving them. MA plans use their own internal criteria for determining whether a service is medically necessary. Some people face serious barriers to care, and some are being denied access to necessary treatment, according to the OIG. Medicare Advantage plans have found ways to game the system.
One critical problem is the way we reimburse Medicare Advantage. We pay them more if they report that their enrollees have more serious health conditions than people in traditional Medicare. So, to maximize revenues, Medicare Advantage plans send providers to enrollees’ homes to find more diagnoses codes for these enrollees, even though the Medicare Advantage plans provide no more care to them.
MA can use prior authorization as a way to ensure people do not get care they do not need. But, some MA plans impose inappropriate prior authorization requirements that are out of sync with standard medical practice. Too many providers must jump through hoops to get their patients needed care and to get paid for the care they provide.
Some MA plans deny care inappropriately at high rates; when claims are appealed, they are reversed 75 percent of the time. Not surprisingly, the GAO found that people disenroll from MA at twice the normal rate in their final year of life, when care is most critical and they need a lot of care.
As for quality of care, MedPac reports that the data on services Medicare Advantage plans provide their enrollees has been historically inadequate or difficult to substantiate. After a decade, MA plans are “not producing complete and accurate enough records needed for MedPac to conduct oversight activities, to understand differences in service use between MA and FFS, to reflect utilization management techniques, and inappropriate denial of covered care.” The government needs to penalize MA plans that have failed to provide complete and accurate data, as required.
There’s also no meaningful accounting as to whether people are using their supplemental benefits in Medicare Advantage, how much is being spent on these additional benefits, and whether they are delivered at a reasonable cost. More transparency is needed.
On top of that, according to MedPac, the Quality Bonus Program, through which the government rewards MA plans delivering better quality care, is fundamentally flawed.
Agencies representatives also said that private sector efficiencies have not reduced the cost of care. Moreover, the Centers for Medicare and Medicaid Services (CMS) is supposed to be auditing health plans and recouping overpayments. Audits have shown widespread overcharging among Medicare Advantage plans. But, CMS audits of MA plans are not timely. CMS has not completed audits from as far back as 2011.
In short, substantial MA reforms are rapidly needed. MA plan incentives are not adequately aligned with those of the people they serve or taxpayers. The Administrator of the Centers for Medicare and Medicaid Services declined to participate in the hearing, though she was invited, reports Fred Schulte of Kaiser Health News.
Here’s more from Just Care:
- Medicare ratings of Medicare Advantage plans a farce
- The Medicare Advantage scam and beyond
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- OIG finds widespread inappropriate care denials in Medicare Advantage
- If you want easy health care access and good quality care, you probably want traditional Medicare
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