Medicare What's Buzzing

Senators ask Medicare agency why it is not holding Medicare Advantage plans accountable for violating their contractual obligations

Written by Diane Archer

On September 13, 2019, six Democratic Senators sent a letter to Center for Medicare and Medicaid Services (CMS) Administrator, Seema Verma, detailing their concerns about the well-being of people enrolled in Medicare Advantage plans and the integrity of the Medicare Advantage program. The Senators ask CMS why it is not holding Medicare Advantage plans accountable for violating their contractual obligations; rather, Medicare Advantage plans are jeopardizing the health and safety of their members and overbilling taxpayers to the tune of around $10 billion a year.

The letter, signed by Senators Sherrod Brown, Debbie Stabenow, Chris Murphy, David Blumenthal, Amy Klobuchar and Bernie Sanders, urges prompt action of Administrator Verma to ensure that Medicare Advantage plans are held accountable for meeting their contractual obligations and managing the health care needs of their members. The Senators want to ensure that deficiencies in oversight of Medicare Advantage plans are addressed. The Senators pose 19 questions to Verma on six areas of concern.

Recouping and preventing Medicare Advantage plan overpayments: Government audits show tens of billions of dollars in overpayments to MA plans and an inability of CMS to recoup this money. Four questions focus on the need for Congress to ensure the financial integrity of the Medicare Advantage program and protect the US Treasury. CMS needs to explain whether and how it plans to recoup overpayments from MA plans. If it can’t recoup this money, CMS needs to explain its plans to ensure it does not continue to overpay them. The Senators ask whether CMS has the tools to hold the Medicare Advantage plans accountable.

Ensuring network adequacy and accurate provider directories: Government audits reveal that provider directories are often inaccurate, and it is not evident that CMS is ensuring network adequacy. Three questions go to why Medicare Advantage plans are not publishing accurate provider directories as required by law and what’s keeping CMS from ensuring there are enough health care providers in the plan’s network.

Securing encounter data, which show the health care services MA plan members receive: Government audits reveal that Medicare Advantage plans are not providing CMS with complete and accurate encounter data as required by law. Two questions ask how CMS is going to secure, report and ensure the accuracy of Medicare Advantage plan encounter data. The Senators support MedPAC’s recommendation that CMS reduce payments to Medicare Advantage plans that do not provide complete and accurate data.

Holding Medicare Advantage plans accountable for persistent performance problems: Government audits show that Medicare Advantage plans may be inappropriately delaying and denying care and coverage to their members. Five questions concern how CMS enforces MA plan standards and protects enrollees, particularly when their health and safety are at risk, as well as whether CMS needs additional resources. The Senators ask CMS to report those Medicare Advantage plans with performance problems and the nature of those problems on the Medicare Plan Finder.

Ensuring star-ratings are not misleading: Medicare Advantage plans found to threaten members’ health and safety can receive four and five-star ratings. The Senators ask what CMS is doing to address these misleading star-ratings.

Ensuring informed health plan choices: CMS has not provided people with Medicare information on plans with high denial rates and plans that have been found to threaten people’s health and safety. It does not disclose that people who forego traditional Medicare when they first enroll may not be able to switch later, since plans that fill gaps in coverage may not be available to them. It does not mention that people enrolled in Medicare Advantage plans could be liable for as much as $6,700 out of pocket for in-network care alone. And, CMS has steered people into Medicare Advantage plans with misleading information.

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