Congress needs to crack down on Medicare Advantage health insurance for the elderly, who may overcharge the government for billions of dollars each year, while denying critical care for patients, government observers said Tuesday. Told the house panel.
Witnesses sharply criticized fast-growing health insurance at a hearing held by the Energy Commerce Subcommittee on surveillance and investigation. They cited a number of important audits and other reports explaining plans to deny access to healthcare.
Subcommittee chairman Diana Deget (D-Colo.) Said that older people should not “jump over numerous hoops” to access health care.
Watchdog also recommends imposing restrictions on “health assessments” at home, arguing that these visits can artificially inflate payments for plans without providing adequate care to patients. did. They also have a founding audit program at the Medicare & Medicaid Service Center (CMS) that is more than a decade behind in recovering billions of dollars on suspicion of overpayment for health insurance, primarily operated by private insurance companies. I asked for a resurrection.
In connection with the refusal of treatment, Erin Bliss, an assistant inspector at the Department of Health and Human Services, said a Medicare Advantage plan was “medically necessary to rule out life-threatening diagnoses.” He said he refused the request for a imaging (CT) scan. aneurysm). ”
With health insurance, the patient first had to undergo an x-ray examination to prove that a CT scan was needed.
“Medicare Advantage may not be aware that older people may face significant barriers to accessing certain types of healthcare services than the original Medicare,” Bliss said. rice field.
Last year’s seniors dropped out of the Medicare Advantage program at twice the rate of other patients leaving the plan, said Leslie Gordon of the Government Accountability Office, a parliamentary oversight department.
Frank Palon, Jr. (DN.J.), chair of the Influential Energy Commerce Commission, heard that some patients are facing “unjustified barriers” to receiving treatment. “I am deeply concerned.”
With the original Medicare, patients can see the doctor of their choice, but may need to purchase a supplemental policy to fill the coverage gap.
The Medicare Advantage Plan accepts a fixed fee from the government to cover personal health care. This plan offers additional benefits such as dental care and can reduce the patient’s out-of-pocket burden, but as a trade-off it limits the choice of healthcare provider.
Aside from these trade-offs, Medicare Advantage has clearly proven to be attractive to consumers. The number of subscribers has more than doubled in the last decade, reaching nearly 27 million in 2021. This is almost half of Medicare’s total population, and the trends many experts predict will accelerate as the baby boomer generation retires.
James Matthews, who heads the Medicare Payment Advisory Board, which advises Congress on Medicare policy, said Medicare Advantage can reduce costs and improve health care, despite its widespread acceptance among older people. “We do not meet this possibility,” he said.
The hearing witness list was particularly absent from anyone at the CMS running the $ 350 billion annual program. The agency passed, even though the Republican Commission sought testimony from CMS administrator Chiquita Brooks-La Sure. Rep. Kathy Rogers (R-Wash.) Said that the CMS was “disappointed” and “missed the opportunity” to punt.
The CMS did not respond to the request for comment in time for publication.
Medicare Advantage, a leading health insurance company, said in a statement that Medicare Advantage “provides better services, access to care and value to nearly 30 million seniors, people with disabilities and American taxpayers.” Announced.
At a hearing on Tuesday, both Republicans and Democrats categorically supported the program and emphasized the need to improve the program. Still, the details and extent of the criticism were unusual.
More generally, hundreds of lawmakers oppose the reduction of Medicare Advantage and cite its growing popularity.
At a hearing, the guard dog sharply criticized the long-standing controversial home visit. Medicare Advantage pays high fees to sick patients, so health insurance can benefit from making patients look more sick than they are on paper. According to Bliss, Medicare paid $ 2.6 billion in 2017 for a diagnosis backed only by a health checkup. She said 3.5 million members did not have a record of caring for the medical conditions diagnosed during their health assessment visits.
The CMS chose not to attend the hearing, but authorities were clearly aware many years ago that some health insurance companies were abusing payment systems to increase profits.
The CMS has aimed to change the situation since 2007, when it developed an audit program called “Risk Adjustment Data Validation” or RADV. The health plan was instructed to send a CMS medical record documenting the health status of each patient and return payment if not possible.
The results are disastrous, showing that 35 of the 37 plans chosen for the audit were sometimes paid thousands of dollars per patient. Common conditions that were exaggerated or unverifiable ranged from diabetes with chronic complications to major depression.
Still, the CMS has not yet completed an audit dating back to 2011. This was expected by authorities to recoup over $ 600 million in overpayments caused by unconfirmed diagnoses.
In September 2019, KHN filed a suit against the CMS under the Information Disclosure Act, forcing the agency to release audits from 2011, 2012, and 2013. The audit claimed by the agency has not yet been completed. CMS plans to release an audit later this year.
KHN (Kaiser Health News) is a national news room that produces detailed journalism on health issues. KHN is one of the three main operational programs of KFF (Kaiser Family Foundation), along with policy analysis and polling. KFF is a donated non-profit organization that provides the public with information on health issues.
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