JustCare

Tag: Sherrod Brown

  • Kaiser Health News sues CMS for Medicare Advantage audits

    Kaiser Health News sues CMS for Medicare Advantage audits

    On September 26, Kaiser Health News brought a Freedom of Information Act suit (FOIA) against the Centers for Medicare & Medicaid Services (CMS) in order to secure 90 Medicare Advantage audits showing hundreds of millions of dollars in overcharges.

    The government audits have never been subject to public scrutiny. However, we do know the health plans that have been charged with bilking the government. Aetna, Humana, UnitedHealth and Wellpoint are all implicated, among others.

    Kaiser’s editor-in-chief, Elisabeth Rosenthal, believes that the public should see the details of these overpayments. The companies implicated are serving people with Medicare. It’s due time they be held to account and stopped from overbilling the federal government.

    Kaiser requested the audit information directly from the Centers for Medicare and Medicaid Services on July 3, 2019. CMS did not respond to the request. Kaiser argues in its lawsuit that CMS’ failure to respond to its request represents a violation of FOIA. It seeks immediate release of the documents.

    Inexplicably, CMS is treating Medicare Advantage plans in a different way from other medical businesses. CMS publicly discloses audits of other medical businesses.

    Federal government audits reveal that Medicare Advantage plans are overcharging the federal government–taxpayers–some $10 billion a year and have been overcharging the government for many years. Medicare Advantage plans claim their members are in worse health than they actually are in order to receive higher payments from the government. They have not presented evidence to justify their claims.

    For years, Medicare Advantage plans have been required by law to turn over data showing the services their members are receiving. And, for years, audits have found the limited data they release to be incomplete and inaccurate. Last month, Senator Sherrod Brown and five of his Senate colleagues wrote CMS expressing their concern about Medicare Advantage overpayments and other activities in violation of their contractual obligations.

    The amount of Medicare Advantage overcharges is likely far higher than we know. Federal audits only capture a fraction of the billings. The federal government has wanted to extrapolate the billing error rate across the universe of Medicare Advantage plan members. But, the commercial insurers that offer Medicare Advantage plans are opposing this, claiming it would be unfair to them.

    Of course, the more money that CMS claws back from the Medicare Advantage plans, the less money the Medicare Advantage plans have to profit at the level they have been profiting. So, they are also threatening to leave Medicare.

    In 2014, the Center for Public Integrity won a lawsuit against CMS forcing it to release audits of Medicare Advantage plans. In that instance, the information released showed that CMS overpaid virtually all the Medicare Advantage plans, in 150 instances by as much as $10,000 a patient a year.

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

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

    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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