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Tag: Medicare Advantage

  • John Oliver: The Medicare hospice scam

    John Oliver: The Medicare hospice scam

    Hospice offers comfort care for people with six months or less to live. Medicare covers hospice care. But, unscrupulous hospice agencies manipulate the Medicare hospice benefit for their benefit, John Oliver reports on Last Week Tonight.

    About 1.8 million people with Medicare receive hospice care each year. Hospices can provide critical support for patients and their families. The best hospices spend a few hours a day several days a week with patients; they rarely offer round-the-clock care so people usually need caregivers at home to care for them when the hospice staff are not there. Unfortunately, many hospice agencies have been found to engage in fraud, costing Medicare hundreds of millions of dollars every year.

    An English doctor and social worker came up with the notion of hospice to allow patients at the end of life to spend their last few months in peace with social and emotional supports. People in the US began receiving hospice services in 1974.

    Six thousand hospice providers in the US today are for-profit. Medicare generally pays them about $200 a day for each hospice patient, regardless of the actual amount of care they deliver. They can earn $1,500 a day for “crisis care.” Bad actor hospices try to sign up as many patients as possible and deliver as little care to them as possible.

    Hospices collect Medicare payment and then maximize their profits by providing little or no services. Oliver reports some instances of “severe neglect.” In many cases, the hospices simply phone patients to check in on them.

    Agencies bill Medicare for patients in hospice who do not belong in hospice. Sometimes hospices enroll patients who are not terminally ill to increase their revenue and defraud Medicare. In California, some hospices have discharged more than 50 percent of their patients without their dying.

    Physicians are required to certify that people qualify for Medicare hospice. But, hospices pay physicians to declare patients are terminally ill when they are not. One physician received a kickback of $250 a patient for certifying patients who were not terminally ill as terminally ill.

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  • Medicare Advantage plans continue to endanger hospitals and patients

    Medicare Advantage plans continue to endanger hospitals and patients

    Jakob Emerson reports for BeckersHospital on the plight of hospitals dealing with Medicare Advantage plans. The insurers offering Medicare Advantage plans often try to maximize profits by denying payments to hospitals inappropriately. Or, they refuse to pay for patient inpatient stays and downgrade them to outpatients stays, which cost less. In short, Medicare Advantage plans continue to endanger hospitals and patients.

    Patients are beginning to feel the unhappy consequences of insurer misbehavior towards hospitals. In some cases, Medicare Advantage plans are denying patients needed care or forcing them to jump through multiple hoops in order to get critical care. Hospitals are cancelling their Medicare Advantage contracts, leaving patients to scramble to find other network providers. This year alone, at least 17 hospital systems have cancelled or will cancel their Medicare Advantage contracts.

    More than half the Medicare population is now enrolled in a Medicare Advantage plan, so hospitals tend to need the Medicare Advantage business. At the same time, they face financial risks when they contract with the insurers offering Medicare Advantage plans. S&P Global’s new report finds hospitals extremely vulnerable to Medicare Advantage bad acts.

    The risks to hospitals is only growing, as the insurers in Medicare Advantage are wildly overpaid. It is more than likely that Congress and the administration will do more to eliminate these overpayments. When that happens, the hospitals will likely face even more challenges getting paid appropriately by Medicare Advantage insurers.

    Another deep concern with Medicare Advantage is that there’s no counting on insurers to stay in business from one year to the next. Three big insurers, Centene, Aetna and Humana are saying they are pulling out of some of the Medicare Advantage markets in 2o25. The government and Medicare Advantage enrollees cannot rely on insurers to continue offering Medicare Advantage plans.

    If they continue in business, there’s also no counting on insurers to keep their Medicare Advantage provider networks, cost-sharing and additional benefits. Insurers can narrow their provider networks, increase cost-sharing, and eliminate additional benefits. Everything can change.

    “[W]e expect insurers to prioritize margin over membership, and we expect large insurers will use their scale and market clout to limit provider rate increases over what will prove to be a challenging contract negotiation season,” reports S&P Global.

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  • McKinsey weighs in on how Medicare Advantage plans can maximize profits

    McKinsey weighs in on how Medicare Advantage plans can maximize profits

    In a new report, McKinsey offers insurers advice on how Medicare Advantage plans can maximize profits. McKinsey focuses on “star” power, keeping Medicare Advantage star ratings at four or higher, and paying more hospitals and physicians fixed rates rather than for each service performed. Make no mistake, this advice will help insurers, not Medicare Advantage enrollees.

    The star-ratings in Medicare Advantage remain a farce for several reasons. Most important, the star-ratings do not capture high denial rates or high mortality rates, two indicia of poor performance and high risk for anyone joining a Medicare Advantage plan. The stars also do not capture basic metrics, such as network adequacy at the Medicare Advantage plan level, but only at the MA insurer contract level, which includes multiple plans. Consequently, a network could look very good at the contract level and deliver a high score to some Medicare Advantage plans, which have poor networks.

    It’s easy for Medicare Advantage insurers to game the star-rating system. And, so long as they get a four or five-star rating, they get additional money from the federal government.

    When insurers pay their network providers a fixed capitated rate rather than fee-for-service, as McKinsey recommends, it can lead to poor care for enrollees. Physicians have a powerful incentive to reject patients with complex conditions, because they cost the physicians too much money. Physicians also have a powerful incentive to not refer patients to costly specialists, because that too can cost them money.

    We still have little clue of the health outcomes for people in Medicare Advantage plans who have complex and costly conditions; the data we do have is troubling. The data show higher disenrollment rates from Medicare Advantage and widespread inappropriate delays and denials of care.

    McKinsey, health insurers, and many others use the Orwellian term “value-based” care to describe the capitated payment system. But, value is made up of quality and costs. And, Medicare Advantage plans have never shared the complete, accurate and timely data that would allow outside independent experts to assess their quality. Moreover, we know that Medicare Advantage plans’ costs to the Medicare program are significantly higher than Traditional Medicare’s.

    Based on the overall quality unknowns of Medicare Advantage, the available data that too often shows delays and denials of care and its high cost, you could say that Medicare Advantage value-less care. Don’t tell us about your performance, Medicare Advantage plans, don’t hide your data, show us what you do, and outside independent experts will report on your performance.

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  • 2024: Too little known about Medicare Advantage

    2024: Too little known about Medicare Advantage

    The Kaiser Family Foundation lays out what Medicare Advantage plans–the health plans administered by corporate health insurers–are doing for their Medicare members in 2024. The Medicare Advantage plans disclose limited data on their performance. They are all too likely to be inappropriately delaying and denying care for anyone with a complex and costly condition because that’s one way they can maximize profits.

    The insurers offering Medicare Advantage plans receive, on average, $2,329 more per enrollee than the government spends on enrollees in Traditional Medicare as a result of a defective payment system. With this money, they can offer an out-of-pocket cap and other appealing-sounding benefits to members. But, they pocket much of this money to benefit their shareholders, and people in Medicare Advantage often struggle to get the Medicare benefits to which they are entitled.

    People in Medicare Advantage, unlike in Traditional Medicare, frequently cannot get the care they want from the physicians they know and trust. In Traditional Medicare, they are covered for reasonable and necessary services from most doctors and hospitals anywhere in the country. In an HMO, they can’t get care outside their community generally; moreover, they often need approval for costly and complex services from their Medicare Advantage plans before they will be covered.

    It’s concerning that there’s so little data reflecting what the Medicare Advantage plans are doing with the money the government gives them. We don’t know what MA plans spend and don’t spend on care, or how often they deny costly services. We don’t know how many hoops each MA plan puts people through or the extent to which each MA plan discriminates against different subpopulations of people with Medicare.

    We do know that 99 percent of people in Medicare Advantage plans must get prior authorization before they can get certain services. Generally, skilled nursing and rehab care, Part B drugs, inpatient hospital stays and psychiatric services all require prior authorization.

    As Medicare Advantage insurers have learned to game the Medicare payment system–largely by relying on physicians and nurses to add diagnosis codes to patient records, even when they are not treating patients for these conditions–the insurers  have been able to offer a little bit more in the way of supplemental benefits to their members. People often join Medicare Advantage plans for these benefits. But, it’s unclear how many people actually receive these benefits; the data is unavailable. And, it’s equally unclear what basic Medicare benefits they give up–as a result of inappropriate denials of care–in exchange for these supplemental benefits.

    To be more specific, it’s unclear how valuable a Medicare Advantage plan’s dental benefit is. It’s not standardized. So, depending upon the Medicare Advantage plan, it could only cover care from a small number of dentists or only cover a small fraction of the total cost of dental services or only cover a cleaning. Copays can be high.

    People in Medicare Advantage have an out-of-pocket limit on their costs, if their Medicare Advantage plan is willing to cover the care their treating physicians say they need. The limit averages $4,882 for people in HMOs and $8,707 for people in PPOs. Traditional Medicare limits people’s costs to 20 percent of its approved amount with no ceiling.

    Here’s more from Just Care:

  • Home visits: Another way Medicare Advantage plans gouge taxpayers

    Home visits: Another way Medicare Advantage plans gouge taxpayers

    Policymakers who claim to be tough on crime continue to turn a blind eye to what appears to be multi-billion dollar corporate health insurer crimes in Medicare Advantage. Anna Wilde Mathews and colleagues report for The Wall Street Journal on millions of home visits to Medicare Advantage enrollees that increased insurer revenues by $15 billion in three years.

    The government’s defective payment system to insurers rewards them for adding diagnoses codes to their enrollees’ medical records. When nurses conduct homes visits, they identify new diagnoses that increase insurer revenues from the government. Insurers can add diagnosis codes to enrollee records even if a doctor doesn’t perform a procedure to treat the diagnosis.

    By the WSJ’s account, the nurses conduct screenings during their home visits that permit the insurers to collect $1,818 more on average per visit. In total, between 2019 and 2021, those visits lined the insurers’ pockets by an additional $15 billion.

    UnitedHealth was best equipped to squeeze money out of those nurse home visits, collecting $2,735 per visit on average. It conducted 2.7 million nurse visits last year alone. Humana did a relatively good job of maximizing revenues from those home visits, collecting $1,525 per visit on average. CVS/Aetna received an additional $232 per nurse home visit.

    One former UnitedHealth nurse explained that she did an average of six home visits each day. As part of the visit, she would warm up people’s toes to see how well blood flowed to them. The goal was to diagnose them with peripheral artery disease, which would mean an average of $2,500 a year more for UnitedHealth.

    The nurse said she did not believe that the device she used for the test worked properly to diagnose peripheral artery disease. But, no one seemed to care, and she was told to keep using it. UnitedHealth added the diagnosis to 568,000 medical records over the three years, as a result of using this device.

    “Other nurses interviewed by the Journal said many of the diagnoses that home-visit companies encouraged them to make wouldn’t otherwise have occurred to them, and in many cases were unwarranted.”

    UnitedHealth received $1.4 billion from the peripheral artery disease diagnosis. Medicare says it is no longer making additional payments to insurers for peripheral artery disease diagnoses.

    UnitedHealth appears to take the cake when it comes to additional patient diagnoses from the nurse home visits. Its nurses detected hyperaldosteronism 246,000 times over the three-year period the WSJ investigated, which was worth $450,000 to the company. All other insurers combined diagnosed the condition less than 24,000 times and collected $42 million as a result.

    The WSJ had previously reported that insurers billed Medicare $50 billion for enrollee health conditions that physicians never treated. Of that, thirty percent stemmed from nurse home visits. The WSJ found that many diagnoses were wrong or questionable.

    To be sure, a nurse’s home visit could be helpful to a patient. The nurse could help with medication management, for example. But, considering that the WSJ found little if any follow-up after these nurse visits, the real benefits is to the bottom lines of the health insurance companies offering Medicare Advantage.

    Here’s more from Just Care:

     

  • More hospitals are dropping Medicare Advantage

    More hospitals are dropping Medicare Advantage

    Jakob Emerson reports for Becker’s Hospital Review that at least 17 large hospital systems are dropping their Medicare Advantage contracts this year. As we’ve seen over the last couple of years, hospitals are making clear that Medicare Advantage enrollees risk not getting needed care in a timely manner, if at all. In addition, with hospitals refusing to be part of Medicare Advantage networks, Medicare Advantage enrollees are struggling to access hospital services.

    More than 30 million older adults and people with disabilities are now enrolled in Medicare Advantage plans. The insurers offering Medicare Advantage plans mislead them to believe that they will get all the benefits of Medicare and more, as they should, in Medicare Advantage. But, report after report shows that Medicare Advantage enrollees face huge obstacles to care when they most need it. They face bureaucratic prior authorization hurdles when they have cancer, or need rehab or skilled nursing services as well as other costly treatments. Their Medicare Advantage plans too often deny them critical care.

    Hospital systems offer several reasons why they are ending their Medicare Advantage contracts. The biggest reason, by far, is that Medicare Advantage plans deny care excessively through their prior authorization processes. And, when patients get care, Medicare Advantage plans too often do not reimburse the hospitals for the care they get.

    A recent survey of 135 health system CFOs by the Healthcare Financial Management Association found that 16 percent intend to end contracts with at least one Medicare Advantage plan in the next two years. Nearly half of them reported that they are considering cancelling their Medicare Advantage contracts. Sixty-two percent said that it had become increasingly more difficult to get the Medicare Advantage plans to pay for the care the hospitals provide.

    UnitedHealth and Humana are the two insurers with the largest share of Medicare Advantage enrollees. They appear to be among the worst offenders when it comes to prior authorization abuses and denied payments from the hospital systems’ perspective.

    In Canton, Ohio Aultman Health System is ending its hospital and physician contracts with Humana Medicare Advantage. Med Health System in Albany, New York, Power Health in Munster, Indiana, Memorial Hermann Health System in Houston, Texas, WellSpan Health  in York, Pennsylvania, Christiana Care in Newark, Delaware, EcuHealth in Greenville, North Carolina, and Genesis Healthcare System in Zanesville, Ohio either have cancelled or will cancel their Humana Medicare Advantage contracts this year.

    Comanche County Memorial Hospital in Lawton, Oklahoma is ending its UnitedHealthcare Medicare Advantage contract as is Samaritan Health Services in Carvallis, Oregon and Health Partners in Bloomington, Minnesota.

    Powers Health and MyMichigan Health are cancelling their Aetna Medicare Advantage contracts.

    Genesis Healthcare System also dropped its Anthem BCBS Medicare Advantage contract.

    Here’s more from Just Care:

  • Low-income communities are particularly at risk in Medicare Advantage

    Low-income communities are particularly at risk in Medicare Advantage

    Insurers offering Medicare Advantage plans too often delay and deny care inappropriately. If you happen to live in a low-income community, you are more likely to be forced to join a Medicare Advantage plan that does not cover the care to which you are entitled under Medicare, according to a new analysis by Avni Gupta et al. published in JAMA. This analysis adds to the mountains of evidence that insurers are fostering health inequities among Black, Hispanic and other vulnerable Americans in Medicare Advantage.

    To be clear, you should not assume that if you are a middle-class white American in a Medicare Advantage plan that you will get the care you need. Even Medicare Advantage plans with five-star ratings delay and deny care inappropriately. And, there is no way for you to know which ones do.

    You are better off in traditional Medicare if you get sick and need costly and complex care. You can choose your physicians and you will get the care you need in a timely manner without bureaucratic hassle. But, you will need Medicare supplemental insurance or Medigap, to protect you from financial risk. With Medigap you will have few out-of-pocket costs, but it will cost you around $2,500 a year. While Medicare Advantage plans have an out-of-pocket cap, your out-of-pocket costs for in-network care alone can be as high as $8,850 this year, depending upon the Medicare Advantage plan you join. If you go out-of-network, your costs will be even higher.

    But, if you live in a low-income community, you are more likely to have fewer choices of Medicare Advantage plans with five-star ratings. And, it is fair to assume that plans with one, two, three and four-star ratings should be avoided. If a plan is not able to earn a five-star rating, there’s likely something wrong with its performance.

    Put differently, it is harder to enroll in a Medicare Advantage plan with a five-star rating if you live in a community with greater poverty and unemployment. As a result, you are likely to experience worse health outcomes. Specifically, you are more likely to receive poorer chronic care management and less likely to receive screenings and vaccinations. Customer service is more likely not to be good. And, if your Medicare Advantage plan inappropriately denies the care you need, it could be harder to challenge that denial.

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  • Voters overwhelmingly support adding dental benefits to Medicare

    Voters overwhelmingly support adding dental benefits to Medicare

    Voters overwhelmingly support adding dental benefits to Medicare, reports BusinessWire. But, will Congress ever do so? Dentists are a big obstacle to receiving dental care as are the costs of dental care, yet the costs of not getting care for your teeth can be brutal.

    In a bipartisan poll, 92 percent of voters support adding a dental benefit to Medicare. And, for good reason. Your oral health can seriously affect your mental and physical health. Without proper dental care, millions of older adults have lost their teeth or struggle from gum disease and then struggle to get proper nutrition.

    Right now and historically, more than 30 million older adults and people with disabilities lack dental coverage.  A lot of the people who have dental coverage can’t use it, either because out-of-pocket costs are still prohibitively high or there are other limitations on their coverage. Although Medicare does not cover routine dental care and most other dental care, Medicare recently began to provide some cancer patients with some dental coverage.

    People often join Medicare Advantage plans because these plans often say they offer dental benefits. But, when you look under the hood, their dental benefits tend to be hollow. As a result, high percentages of people in Medicare Advantage plans have not gone to the dentist in the last year.

    Medicare dental benefits are a top priority for Democrats and Republicans alike. Americans support dental benefits as much as they support abortion rights.

    Congress is well aware of the need for a Medicare dental benefit, but has yet to pass a Medicare dental benefit. Senator Sanders introduced a bill in the Senate to expand Medicare dental benefits and improve them in Medicaid. The bill also gives dental benefits to veterans through the Veterans Administration.

    The dental industry, which does not want to see its rates regulated, opposes a dental benefit. Dentists already have a good supply of patients because there is a huge shortage of dentists in the US, with 58 million Americans living in dental deserts. And, they say they do not want to deal with Medicare’s administrative burdens.

    Increasingly, states are allowing dental therapists to treat cavities and other dental needs without supervision from dentists, as a way to help ensure people get dental care. Dental therapists can provide people with temporary crowns and remove teeth that have decayed. While they do not have as much training as a dentist, they have more training than a dental hygienist.

    Alaska, Arizona, Colorado, Connecticut, Idaho, Maine, Michigan, Minnesota, Nevada, New Mexico, Oregon, Vermont, Washington and, Wisconsin all permit dental therapists to provide certain dental care.

    Hundreds of thousands of Americans travel out of the country for their dental care. Mexico offers dental care at far lower cost than in the US.

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  • Wall Street Journal exposes how insurers game Medicare Advantage, costing taxpayers nearly $600 billion

    Wall Street Journal exposes how insurers game Medicare Advantage, costing taxpayers nearly $600 billion

    Christopher Weaver and others report for The Wall Street Journal on how Medicare Advantage insurers game the payment system. They reap tens of billions of additional  dollars each year through false claims that their enrollees have health conditions that they do not really have. The Medicare Advantage payment system is defective, cheating taxpayers. What will it take for Republicans and Democrats in Congress to eliminate these overpayments and reform the payment system in Medicare Advantage?

    The Medicare Advantage plans hire nurses to visit enrollees and identify additional health conditions for them. They even give $50 gift cards to enrollees who allow these nurses to visit them at home. With new diagnosis codes on patient records, Medicare pays Medicare Advantage insurers billions of additional dollars, driving up Part B premiums for everyone with Medicare and ripping off taxpayers.

    UnitedHealth is one of the insurers that engages nurses to visit their enrollees at home. In some cases, nurses find “diabetic cataracts” which leads to as much $2,700 in additional Medicare payments for a single enrollee in a year. But, sometimes, if not more often than that, the enrollee has neither diabetes nor cataracts, the Wall Street Journal found in an analysis of Medicare records.

    Dr. Howard Chen, an ophthalmologist in Arizona, said he had one or two patients each year with diabetic cataracts. But, UnitedHealth reported to Medicare that 148 of his patients had this condition. Compared to patients in Traditional Medicare, UnitedHealth enrollees were 15 times more likely to have diabetic cataracts. When told about this odd disparity, eye experts said that it was not plausible that so many UnitedHealth enrollees could have this condition.

    The Wall Street Journal also found that insurers who add additional diagnoses to patient records often do not provide care to patients with these diagnoses. Even when the additional diagnoses were for deadly conditions that would require treatment, such as AIDS, the insurer provided no follow-up care.

    UnitedHealth reported $8.7 billion for diseases they never treated, such as HIV in 2021. UnitedHealth also kept a Hepatitis C diagnosis on records of more than half of their patients who had completed treatment for the condition and had been cured.

    The WSJ findings add to a chorus of findings from an array of independent experts, revealing the defective Medicare Advantage payment system. Taxpayers have spent more than half a trillion dollars—$591 billion— on Medicare than they would have spent had Medicare Advantage never been enacted, according to the Medicare Payment Advisory Commission. This privatized Medicare Advantage program has been a bust from a cost perspective.

    What’s worse is that Medicare Advantage plans too often deny care inappropriately to enrollees who need costly care. And, still worse, the government has little ability to oversee the insurers offering Medicare Advantage, let alone punish the criminal insurers in a meaningful way. The Centers for Medicare and Medicaid Services, which oversees Medicare, is hard-pressed to cancel their contracts.

    UnitedHealth disputed the WSJ findings saying they were “inaccurate and biased.” But, it provided no evidence to support its claim. In contrast, the WSJ found 66,000 patients diagnosed with diabetic cataracts, when it was not possible. They had had cataract surgery and could not have had cataracts!

    Here’s more from Just Care:

  • Medicare Advantage provides huge gross margins to insurers

    Medicare Advantage provides huge gross margins to insurers

    Page Minemeyer reports for Fiercehealthcare on a new Kaiser Family Foundation (KFF) analysis finding that insurers offering Medicare Advantage plans had the highest gross margins. Medicare Advantage plans in 2023 realized nearly twice the gross margins from their Medicare Advantage enrollees as they did from their enrollees in the individual market. When will government stop wasting billions of taxpayer dollars and stop overpaying insurers offering Medicare Advantage?

    According to KFF, insurers’ gross margins for each enrollee in Medicare Advantage in 2023 were $1,982 as compared to $1,048 in the individual market. While gross margins cannot be equated with profitability, they are a key metric for assessing a company’s financial performance. Gross margins do not account for administrative costs or taxes.

    And, even though insurers suggested that more enrollees in their Medicare Advantage plans in 2023 received costly services than enrollees in 2022, their gross margins were about the same in 2023 as in 2022, $1,977.

    The federal government theoretically caps the amount that insurers can profit through their Medicare Advantage plans. There is what is called a Medical Loss Ratio or MLR, which requires insurers to spend at least 85 percent of their government payment on care; they can keep as much as 15 percent for administrative costs and profits. But, in practice, the insurers have many ways to get around the cap.

    UnitedHealth has done a brilliant job of getting around the cap by acquiring physician practices. It can transfer 85 percent of its government payment to its provider subsidiary and then claim it has met its medical loss ratio requirement.

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