The US Department of Justice (DOJ) has been taking on major enforcement activities to protect people with Medicare and others from health care fraud, something that the Centers for Medicare and Medicaid Services (CMS) needs to do a lot more of. Noah Tong reports for Fierce Healthcare on the more than $1.8 billion in health-care settlements and judgments the Justice Department has recovered in the last fiscal year.
The Justice Department is able to hold health insurers offering Medicare Advantage plans to account under the False Claims Act. In the fiscal year ending 2024, the DOJ recovered $1.8 billion in federal losses.
Will these DOJ activities move the insurers offering Medicare Advantage plans to provide people with the care they are entitled to and not game the payment system and overcharge the federal government? These settlements and judgments should warn them, for sure. As one expert commented, “The [DOJ] press release goes out of its way to signal that Medicare Advantage plans’ risk adjustment practices are DOJ’s most important healthcare fraud priority. It telegraphs that by making MA risk adjustment the first, and most prominent, specific area it addresses.”
Without question, the insurers are taking note. But nothing the Justice Department is doing leaves health insurance corporations with any reason not to continue to delay and deny needed care, if they so choose. That’s how they maximize profits. And, the Centers for Medicare and Medicaid Services has little way to ensure insurers cover the Medicare benefits they are required to cover, let alone to warn people enrolled in Medicare Advantage plans that do not cover these benefits.
There’s also no reason to believe that the same insurers who are gaming the Medicare Advantage payment system are not also gaming the Medicare coverage requirements. The Office of the Inspector General has said that combating fraud is a challenge because there’s no data on denied claims. Why should we trust insurers when it’s in their financial interest to deny and delay care inappropriately?
CMS needs to implement a new MA claims processing system. It needs an independent agency to process all Medicare Advantage claims. Without that, people cannot know whether the Medicare Advantage plan they join will inappropriately deny them the medically necessary care to which they are entitled.
Here’s more from Just Care:
- Medicare fraud: Traditional Medicare v. Medicare Advantage
- Medicare Advantage: Combating fraud is a challenge because there’s no data on denied claims
- Inspector General finds Medicare telehealth fraud
- Whistleblowers expose fraudulent Medicare Advantage billing practices
- CVS charged with healthcare fraud
