James C. Capretta, American Enterprise Institute, argues for changes in Medicare Advantage that “incentivize efficiency and high-quality care without needlessly overpaying the plans.” Who could disagree with that? Unfortunately, “efficiency” can and too often means inappropriate care and claim denials.
Capretta argues for reforms to the Medicare Advantage payment system. For sure, reforms are needed. The government should not be paying the insurers more than it costs to treat people in Traditional Medicare, the government-administered Medicare program. And, right now, estimates are that the government is overpaying the insurers in Medicare Advantage $84 billion this year alone, $1 trillion over the next ten years.
Capretta also argues for standardized benefits in Medicare Advantage to allow people to compare their options. That would be invaluable. And, he suggests, correctly, that to ensure a level playing field and fair competition with Traditional Medicare, “it may be necessary” to add an out-of-pocket cap to Traditional Medicare. This cap would allow people to move easily between Traditional Medicare and MA without needing supplemental coverage to protect themselves financially.
Capretta fails to mention that the government needs to overhaul the way MA insurers determine whether a service is covered. Right now, insurers too often indiscriminately delay and deny Medicare-covered services to their members in violation of their contractual obligations, especially for costly services. They have a financial incentive to do so. The more care they deny, the more they profit.
The government should have a system in place to ensure insurers in Medicare Advantage cover all the medically necessary services they are required to cover.
The government should require that Medicare Advantage insurers process all claims through a centralized Medicare claims administrator, as the Traditional Medicare program, the government-administered Medicare option, does. A centralized claims administrator for MA claims would ensure that everyone with Medicare receives the benefits they are due, as well as coverage consistency across Medicare, It would help prevent insurers from inappropriately denying care for the sake of their shareholders and at the expense of the health and well-being of their enrollees.
The government should also require Medicare Advantage insurers to pay doctors and other providers at the same level as Traditional Medicare. This could expand provider networks and help ensure that insurers are not steering their enrollees to poor quality providers.
Here’s more from Just Care:
- It’s Medicare open enrollment season, here’s what to do and not do
- OIG finds widespread inappropriate care denials in Medicare Advantage
- If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?
- When your doctors leave your Medicare HMO, will the government protect you?
- What could a better Medicare look like?
