JustCare

Tag: Medicare Advantage

  • Attention mounts on Medicare Advantage fraud and abuse

    Attention mounts on Medicare Advantage fraud and abuse

    More Democrats and Republicans in Congress are speaking out and raising alarms about Medicare Advantage. If Republicans need to find savings to pay for their tax cuts, they need look no further than the $1 trillion in Medicare Advantage overpayments.

    A growing number of Republicans are speaking out against these massive government overpayments to Medicare Advantage insurers. At a recent Senate Finance Committee hearing, Senator Roger Marshall (KA-Rep) said: “Like Dr. Oz, I thought Medicare Advantage was a good thing when it came out. But, unfortunately, it’s been manipulated. They found loopholes to manipulate and now we’re spending probably $83 billion more a year on Medicare Advantage patients as opposed to if they had been on traditional Medicare…I hope that there’s an opportunity to fix that very broken system that friends across the aisle who speak so boldly about Medicare Advantage that they will vote for reforming it as well whenever we have that opportunity.”

    Senator Chuck Grassley (Rep-IO) has expressed similar concerns about Medicare Advantage, as have Senators Bill Cassidy (Rep-LO) and James Lankford (Rep-OK), who recognizes inappropriate denials in Medicare Advantage, which are keeping some hospitals in his state from contracting with MA insurers.

    Indeed, increasingly, hospital systems, including some of the best hospital systems in the country are dropping Medicare Advantage contracts. 

    Seventy-eight Democrats in the House of Representatives wrote HHS Secretary Kennedy and Acting CMS Administrator Carlton to express their concerns about Medicare Advantage overpayments and more.”If Republicans were serious about combating waste, fraud and abuse, they would be focused on Medicare (dis)Advantage plans,” says Representative Pramila Jayapal (CA-Dem) on MSNBC.

    Eight Democrats in the Senate sent a similar letter.

    Eileen Appelbaum, health economist at the Center for Economic and Policy Research, explains the Medicare Advantage rip-off here:

    Here’s more from Just Care:

  • Medicare Advantage overpayments drive up Medicare premiums by $220 billion

    Medicare Advantage overpayments drive up Medicare premiums by $220 billion

    If Republicans are serious about eliminating government waste and protecting Medicare and Medicaid, they will end Medicare Advantage overpayments; in addition to strengthening Medicare, ending these overpayments would lower premiums for older adults and people with disabilities by $220 billion. Ending these overpayments would also add $550 billion to the Medicare Trust Fund.

    Ending government overpayments to Medicare Advantage insurers would put spending in Medicare Advantage on a level playing field with traditional Medicare. Ending overpayments would mean reducing already high MA insurer profits, not Medicare benefits. Reducing overpayments would strengthen the Medicare program.

    Here’s the data revealing the excessive costs of Medicare Advantage relative to traditional Medicare as well as the toll it is taking on the out-of-pocket health care costs of older Americans and people with disabilities and the Medicare Trust Fund. 

    Medicare overpays Medicare Advantage insurers

    • “The MA program has been expected to reduce Medicare spending since its inception—under the original incorporation of private plans in Medicare in 1985, payments to private plans were set at 95 percent of FFS payments—but private plans in the aggregate have never produced savings for Medicare, due to policies governing payment rates to MA plans that the Commission has found to be deeply flawed.”
    • According to the Medicare Payment Advisory Commission (MedPac), the program’s watchdog agency, Medicare Advantage plans cost taxpayers 20% more than traditional Medicare, amounting to a projected $84 billion in 2025.
    • The Committee for a Responsible Federal Budget reports that overpayments to MA plans will total  $1.2 trillion dollars over the next decade.
    • A report by the Wall Street Journal of roughly 2 billion diagnoses covering 84% of the nation’s MA enrollees from 2018-2021 found that MA insurers collected $50 billion in payments for diseases that doctors never diagnosed or treated.

    Medicare Advantage overpayments strips billions from the Medicare Trust Fund

    • The Committee for a Responsible Budget reports that eliminating the overpayments would save the Medicare Trust Fund $550 billion.

    Older adults and people with disabilities pay higher premiums because of Medicare Advantage

    Here’s more from Just Care:

  • Medicare adds $25+ billion to Medicare Advantage insurer coffers

    Medicare adds $25+ billion to Medicare Advantage insurer coffers

    The Centers for Medicare and Medicaid Services just announced the final rule regarding Medicare Advantage payments in 2026. Notwithstanding $83 billion in overpayments to MA insurers last year and  this year as well, the Trump Administration opted to increase insurer payments by $25+ billion in 2026.

    The payment increase of 5.06 percent is more than double the proposed increase of 2.23 percent in the Biden administration’s Advance Notice for MA payments in 2026. To be clear, increases in payments to Medicare Advantage insurers end up largely in the form of profits for the insurers, but they also allow the insurers to market “additional benefits” to people with Medicare.

    Beware: If you are enrolled in a Medicare Advantage plan and you are diagnosed with a complex and costly condition, you might not be able to see the specialists you want to see or use the hospitals you want to use. Moreover, you may face inappropriate delays and denials of care. If you want easy access to care, you should enroll in traditional Medicare.

    The serious problem with any payment increase is that the Medicare Advantage insurers are expected to be overpaid more than $1 trillion in the next 10 years. The result is that people with Medicare will be forced to pay $220 billion more in Medicare premiums over the next ten years. Medicare premiums are calculated based on program costs.

    What’s equally concerning is that the Medicare Trust Fund is projected to lose $550 billion over the next ten years as a result of government overpayments to insurers.

    The Centers for Medicare and Medicaid Services claims that the additional boost to MA insurers stems from higher costs in the last quarter of 2024.

    On a happier note, CMS is finalizing the third and last year of the proposed change to the Medicare Advantage “risk-adjustment model” for paying insurers that the Biden administration launched in 2024. The changes are intended to eliminate some of the gaming that insurers engage in to collect more from the government for their services than appropriate.

    Here’s more from Just Care:

  • 2025: Government finalizes new Medicare Advantage policies

    2025: Government finalizes new Medicare Advantage policies

    Last Friday, the Centers for Medicare & Medicaid Services (CMS) issued a final rule regarding Medicare Advantage (MA) and Medicare Prescription Drug (Part D) policy. The rule will take effect in 2026. Of note, the final rule does not call for Medicare coverage of Ozempic or other anti-obesity drugs for people seeking to lose weight, as proposed, nor does it put guardrails on insurers’ use of artificial intelligence to deny care.

    CMS chose not to finalize provisions in the Biden Administration’s proposed rule related to promoting equity, ensuring equitable access to MA services, imposing guardrails for artificial intelligence (AI) or covering anti-obesity medicines.

    The rule does require MA plans to cover inpatient hospital admissions that they approved based through a prior authorization process. MA plans have too often decided post prior authorization approval to deny coverage for inpatient admissions that they deemed, after the fact, should have been treated as outpatient admissions. MA plans can only reopen a prior approval of an inpatient admission because of fraud or administrative error.

    CMS also finalized a rule ensuring that enrollees and providers can appeal an MA denial whether it comes before, during or after a procedure.

    CMS finalized a proposal that prohibits Medicare Part D plans from charging a deductible or copay for adult vaccines that the Advisory Committee on Immunization Practices recommends. The deductible also does not apply to insulin products; and, cost-sharing for these products cannot go above $35.

    In addition, Part D plans must allow enrollees to make monthly payments for their covered drugs over the course of the year, rather than in one lump sum at the pharmacy. Effective this year, these payments cannot exceed $2,000 over the course of the year.

    Here’s more from Just Care:

  • Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.

    Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.

    Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.

    Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.

    Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could  that simply mean a physician rubber-stamping them?)

    Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.

    Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.

    Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.

    Here’s more from Just Care:

  • Republicans look to end Medicare Advantage overpayments

    Republicans look to end Medicare Advantage overpayments

    More members of Congress on both sides of the aisle are looking at ways to end massive overpayments to Medicare Advantage insurers as a means of reducing federal spending, reports Peter Sullivan for Axios. Ending these overpayments should not affect people’s Medicare benefits, it would simply put spending in Medicare Advantage for each enrollee on a par with spending in Traditional Medicare. In sharp contrast, cutting Medicaid benefits would likely cause tens of millions of Americans to become uninsured or underinsured.

  • Senator Grassley takes on UnitedHealth Medicare Advantage overpayments

    Senator Grassley takes on UnitedHealth Medicare Advantage overpayments

    One moderate Republican Senator is concerned about the billions of dollars in government overpayments to UnitedHealth Medicare Advantage. Senator Chuck Grassley, who chairs the Senate Judiciary Committee, sent UnitedHealth CEO Andrew Witty a letter demanding that he release information on the company’s Medicare Advantage government billing practices.

    Countless reports and analyses show that the big Medicare Advantage insurers are overbilling Medicare to the tune of as much as $140 billion a year. The Medicare Payment Advisory Commission more conservatively estimates $83 billion in overpayments last year alone. But UnitedHealth won’t acknowledge that engaging nurses to add diagnoses to their enrollees’ medical records, even when the nurses have no clue what the diagnoses mean and perform no additional tests to determine additional diagnoses, is at the very least wrong, if not outright fraud.

    Senator Grassley wants UnitedHealth to provide Congress will lots of information about their billing practices. Grassley alleged apparent fraud, waste and abuse at UnitedHealth. In 2021, UnitedHealth allegedly benefited to the tune of $8.7 billion from overbilling the government.

    “Despite these oversight efforts, [Medicare Advantage Organizations] continue to defraud the American taxpayer, costing them billions of dollars a year … The apparent fraud, waste, and abuse at issue is simply unacceptable and harms not only Medicare beneficiaries, but also the American taxpayer,” Grassley wrote. Everyone with Medicare pays higher Part B premiums as a result of the overpayments, and the overpayments are eating into the Medicare Trust Fund.

    Grassley wants Congress to examine UnitedHealth’s training manuals, guidance documents, compliance program details, audit results and other documents.

    To be clear, UnitedHealth is the largest Medicare Advantage insurer and, consequently, likely to be reaping the greatest amount in overpayments. But, Humana, CVS Health and Anthem are also beneficiaries of these overpayments. According to the Congressional Budget Office, ending these overpayments would mean $1 trillion in savings over the next ten years.

    Here’s more from Just Care:

  • Congressional Budget Office finds $1 trillion in Medicare Advantage overpayments

    Congressional Budget Office finds $1 trillion in Medicare Advantage overpayments

    Merrill Goozner writes for his Gooznews Substack “if only the GOP was more like Willie Sutton.” Republicans in Congress are working to cut $880 billion from the budget to pay for tax cuts for the wealthy. If they followed the health care money, they would be looking no further than Medicare Advantage.

    The government is currently overpaying insurers in Medicare Advantage about $1 trillion over the next ten years., according to the Congressional Budget Office. This past year alone, overpayments totaled $83 billion according to the Medicare Payment Advisory Commission. Medicare Advantage is the program to target; eliminating overpayments to insurers in Medicare Advantage would help eliminate fraud and waste, strengthen the Medicare Trust Fund and bring down Medicare Part B premiums.

    Republicans want to resurrect Trump’s tax cuts from 2017, which would increase the federal deficit by more than $2 trillion in the next 10 years. Cutting Medicaid, which they are looking to do, would mean major cuts to  hospitals, nursing homes, and other health care providers as well as loss of insurance coverage for millions of low-income Americans.

    Some Republicans are pushing back against House Speaker Mike Johnson because many of their constituents depend upon Medicaid and the federal dollars it brings to their states.

    The House voted on a budget resolution that would cut health care by $880 billion over ten years. Most of that money is likely to come out of Medicaid, although the resolution does not say that. So, there’s still some opportunity to guide Republicans to Medicare Advantage as a source of money.

    Goozner notes that our national debt tends to rise more during Republican administrations than during Democratic administrations.
    Source: Statista; data through 2023

    People in Medicare Advantage are no sicker than people in traditional Medicare–the government-administered Medicare program–even though the insurers would like you to believe otherwise. A new study out of Beth Israel Deaconness Medical Center, published in the Annals of Internal Medicine, found no difference in health status between enrollees in Medicare Advantage and traditional Medicare on four key metrics–obesity, high blood pressure, high cholesterol, and chronic kidney disease. Medicare Advantage enrollees are slightly more likely to have diabetes than traditional Medicare enrollees.

    To address overpayments in Medicare Advantage, the Centers for Medicare and Medicaid Services could simply adjust the amount they pay insurers down by 20 percent or so. Medicare would save about $1 trillion.

    In an editorial accompanying the research paper, Amal Trivedi and Richard Kronick wrote “Policymakers seeking to reduce health spending would better serve taxpayers by curbing MA overpayments rather than targeting Medicaid for savings.” Indeed they would!

    Here’s more from Just Care:

  • Don’t trust social media for wellness advice

    Don’t trust social media for wellness advice

    You likely see dozens of clips each day providing wellness advice. Unfortunately, a lot of what you see on social media and TV should not be trusted. What should you do? Jude Joffe Block reports for NPR on what’s happening on social media. Reed Abelson and Susanne Craig report for the New York Times on the misleading information that Dr. Oz promotes, while benefiting financially.

    Dr. Oz has promoted Medicare Advantage plans endlessly, without warning people that they could struggle getting the care they need in a Medicare Advantage plan. Insurers offering Medicare Advantage delay and deny care inappropriately and routinely, particularly costly care. They have a powerful financial incentive to do so. Every treatment they delay or deny helps maximize their profits. Like the insurers, Dr. Oz profits from promoting Medicare Advantage.

    Dr. Oz also has profited to the tune of tens of millions of dollars from selling supplements, even when there is little or no scientific evidence to show any benefits from the supplements he promotes and, in some cases, people can be harmed.

    Some people are trying to fight online misinformation from wellness influencers with accurate information. That’s tough. You want to be sure that whatever wellness advice you’re taking is based on science and not hokum. You can save money by not consuming products that are of no value or, worse still, harmful to your health.

    Whose wellness advice should you take? You probably should not listen to anyone who makes money from providing wellness advice. Anyone profiting from providing advice has a conflict of interest, including Robert F. Kennedy, Jr., the newly confirmed Secretary of Health and Human Services.

    For example, if you look at the scientific evidence, you should be getting a vaccines for Covid and a range of other conditions, even though RFK Jr. likely disagrees. Medicare covers a range of vaccines. And, for most, you have no out-of-pocket costs so long as you get them from a Medicare participating provider.

    Here’s more from Just Care:

  • Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Instead of gutting Medicaid, Congress could save $1 trillion by ending hundreds of billions of dollars in overpayments to corporate health insurers in Medicare Advantage. A new report by Arnold Ventures details how our federal government could effectively end Medicare Advantage and other health care wasteful spending, save as much as $4 trillion, and not touch Medicaid spending.

    The Arnold Venture report spells out 10 ways for Congress to spend less and 10 ways to close tax loopholes that could pay for a permanent extension of the 2017 Tax Cuts and Jobs Act (TCJA). It proposes four smart ways to spend less on health care.

    Arnold Ventures recommends fixing the broken Medicare Advantage payment system that leads to as much as $140 billion a year in overpayments to corporate health insurers. Insurers use a variety of methods to maximize government payments, including “upcoding.” Insurers add diagnosis codes to enrollees’ medical records, which allows them to bill Medicare at higher rates for these enrollees, even when the insurers provide no additional services to these enrollees. The government could adjust down the rate it pays insurers to reduce overpayments significantly. This policy could save as much as $1 trillion over 10 years.

    If Congress ended overpayments to health insurers, the health insurers would claim that the government was “cutting” people’s Medicare benefits. But, the government would still be spending as much on enrollees in Medicare Advantage as in Traditional Medicare. The government would simply be reducing fraud and waste.

    Arnold Ventures recommends “site-neutral payments,” a policy that would require Medicare to pay the same amount for care in a hospital setting as for care in a physician’s office. For reasons that make little sense other than bolstering hospital coffers, today Medicare pays hospitals as much as four times more when a service is performed in a hospital setting. Hospitals have gamed the Medicare payment system by buying physicians’ practices; they can then legally charge the hospital outpatient rate for services, even though the services are identical to what they were before the hospital owned the practices.

    A few years ago, Congress limited the ability of hospitals to continue to game the Medicare payment system through purchases of physician practices. But, Congress grandfathered in the higher rates for hospital outpatient clinics established before the law passed. Ending this grandfathering provision alone would save $30 to $40 billion over ten years.

    Shockingly, the current Medicare payment system still creates an incentive for hospitals to steer patients to get care in a hospital setting, even when the service can be provided at far lower cost in a physicians’ office. Site-neutral payments could save as much as $157 billion over ten years. It would also lower out-of-pocket costs for people with Medicare.

    Arnold Ventures recommends penalizing pharmaceutical companies if they raise the price of their drugs above the rate of inflation for people in the commercial marketplace. The Inflation Reduction Act enacted this policy for Medicare and Medicaid but not for working people. This policy could save the federal government as much as $40 billion over 10 years.

    Arnold Ventures supports requiring Medicaid managed care plans to pay hospitals and nursing homes no more than the Medicare rate.

    Today, states can direct Medicaid managed care plans to pay hospitals and nursing homes at “average commercial rates.” Those rates are far higher than the Medicaid fee-for-service rates. They also incentivize hospitals with monopoly power to increase their rates, which are already twice Medicare rates. Medicaid managed care plans should not be allowed to pay hospitals and nursing homes more than the Medicare rates. This policy would save as much as $120 billion over 10 years.

    Here’s more from Just Care: