Watchdogs Attack Medicare Benefit For Refusing Care, Overcharged

By Fred Schulte, Kaiser Health News

Wednesday, June 29, 2022 (Kaiser News) — Congress must crack down on Medicare Advantage senior health plans that sometimes deny patients essential medical care while charging the government billions of dollars annually, government watchdogs told a House panel on Tuesday.

Witnesses sharply criticized the burgeoning health plans during a hearing held by the Energy and Commerce Subcommittee on Surveillance and Investigations. They cited a slew of critical audits and other reports detailing plans that denied access to health care, especially those with high numbers of patients being deregistered in their final year of life when they were likely to be in poor health and in need of more services.

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors don’t have to “jump through countless hoops” to access health care.

The watchdogs also advised imposing limits on home-based “health assessments,” arguing that these visits could artificially inflate payments to plans without providing patients with appropriate care. They also called for the Centers for Medicare & Medicaid Services, or CMS, to revive a devastating control program that is more than a decade behind in recouping billions in suspected overpayments to health plans, which are usually managed by private insurance companies.

In connection with the denial of treatment, Erin Bliss, an assistant inspector general in the Department of Health and Human Services, said a Medicare Advantage plan had denied a request for a computed tomography or CT scan that was “medically necessary to exclude a life-threatening diagnosis (aneurysm).”

According to the health plan, patients first had to take an X-ray to prove that a CT scan was needed.

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care in Medicare Advantage than in the original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog division of Congress, said seniors were twice as likely to join Medicare Advantage plans in their final year of life as other patients who left the plans.

Representative Frank Pallone Jr. (DN.J.), chairman of the influential Energy and Commerce Committee, said he was “deeply concerned” to learn that some patients face “unjustified barriers” to getting care.

Under the original Medicare, patients can see any doctor they want, although they may need to purchase additional policies to cover gaps in coverage.

Medicare Advantage plans accept a flat fee from the government to cover one’s health care. The plans can provide additional benefits, such as dental care, and cost patients less out of pocket, although they limit the choice of medical providers as a trade-off.

These trade-offs aside, Medicare Advantage clearly appears to be attractive to consumers. Enrollments have more than doubled in the past decade, reaching nearly 27 million people by 2021. That’s nearly half of all people on Medicare, a trend that many experts believe will accelerate as legions of baby boomers retire.

James Mathews, who heads the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care, but “not reach this potential,” despite widespread adoption. among seniors.

Notably absent from the witness hearing list was someone from CMS, which runs the $350 billion-a-year program. The agency took a pass, even though the committee’s Republicans invited CMS administrator Chiquita Brooks-LaSure to testify. Rep. Cathy Rodgers (R-Wash.) said she was “disappointed” that CMS had scored, calling it a “missed opportunity.”

CMS did not respond to a request for comment in time for publication.

AHIP, which represents the health insurance industry, released a statement saying that Medicare Advantage plans “provide better service, access to care and value for nearly 30 million seniors and people with disabilities and for U.S. taxpayers.”

At Tuesday’s hearing, both Republicans and Democrats stressed the need for improvements to the program, while steadfastly supporting it. Still, the details and level of criticism were unusual.

More typically, hundreds of members of Congress argue against making cuts to Medicare Advantage, citing its growing popularity.

During the hearing, the watchdogs sharply criticized house calls, which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can benefit by making patients look sicker on paper than they are. Bliss said Medicare paid $2.6 billion in 2017 for diagnoses supported by the health assessments alone; she said 3.5 million members had no records of getting care for medical conditions diagnosed during those health assessment visits.

Although CMS chose not to appear at the hearing, officials years ago clearly knew that some health plans were abusing the payment system to increase profits, but for years they ran the program as what one CMS official called an “honor system.”

CMS wanted things to change starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation” or RADV. Health plans focused on sending CMS medical records documenting each patient’s health status and returning payments when they couldn’t.

The results were disastrous, showing that 35 of the 37 plans selected for audit had been overpaid, sometimes by the thousands of dollars per patient. Common conditions that were exaggerated or could not be verified ranged from diabetes with chronic complications to major depression.

Still, CMS has not completed audits dating back to 2011 where officials expected to recover more than $600 million in overpayments caused by unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to force the agency to release 2011, 2012 and 2013 audits — audits the agency says are still pending. CMS is expected to release the audits later this year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three major operational programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.


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