Categorized | Features, Pushback

Medicare Advantage: A Massive Policy Toothache

Medicare Advantage

I can always tell when its Medicare Open Enrollment, that 53-day period from Oct. 15 to Dec. 7. My mailbox fills up with fliers, over-sized postcards and letters inviting me to join a Medicare Advantage plan.

By Al Norman

I can always tell when its Medicare Open Enrollment, that 53-day period from Oct. 15 to Dec. 7. My mailbox fills up with fliers, over-sized postcards and letters inviting me to join a Medicare Advantage plan.

These Advantage managed care plans, also known as Medicare Part C, are owned by private companies, but they have attracted about 28 million Medicare enrollees — about half of the Medicare beneficiaries — away from traditional Medicare by offering plans with $0 premiums that add benefits for dental and eye care, hearing aids, and no copay on many prescription meds. One plan even offered me money to buy sneakers, and a credit card to buy over-the-counter health products. I declined that plan because they did not have my primary care doctor in their list of physicians.

This year I actually researched the option of changing my Advantage plan, because I have grown tired of fighting with my plan’s add-on dental insurance, because getting them to pay anything on a claim is like, well, pulling teeth. And I don’t like paying a $45 copay if I need to see a specialist for an office visit. In the end, I stayed with the Advantage plan I’ve had for several years — but it doesn’t seem like a great “advantage” to be in this health plan.

premium, patient-centered, Social Security, ageist, nursing, COVID, Trump, vaccineI found it ironic timing that shortly before the Medicare Advantage Open Enrollment kicked off, a news story broke that the Centers for Medicare and Medicaid Services (CMS), which manages Medicare, had agreed to publicly release audits they conducted on dozens of private Medicare Advantage health plans to settle a 2019 lawsuit filed by Kaiser Health News (KHN). These were not recent audits — some of them went as far back as 2011 to 2013—but they were reviews of the “Medicare Advantage Risk Adjustment Data Validation”. KHN argued in its lawsuit that CMS was withholding these Medicare Advantage audits, which showed more than $650 million in improper charges. Not something that builds confidence in these plans.

After three years of ignoring the Freedom of Information Act lawsuit, CMS did not admit to wrongfully withholding the requested documents —but they did agree to pay $63,000 in legal fees, and told KHN they would release as many as 90 audits by early December. When the lawsuit was first filed in 2019, it was alleged that these Advantage plans over the preceding 3 years had overcharged the Medicare program by $30 billion. KHN said the released audits would show the taxpayers that Medicare Advantage plans had overcharged Medicare several hundred million dollars. A lawyer representing KHN in the suit, told The Hill newspaper, “It’s incredibly frustrating that it took a lawsuit and years of pushing to make this vital information public.”

The audit list was like a Who’s Who of Medicare Advantage corporations: United Heath Group, Anthem, Cigna, Tufts HMO, Aetna, Blue Cross of Minnesota and Florida, Wellpoint, Kaiser Foundation Health Plan and Humana. The Federal government has accused these companies of using schemes to secure risk adjustment overpayments from CMS. The New York Times reported that United Health Care “told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.”

“Major health insurers exploited the program to inflate their profits by billions of dollars,” the Times reported.

Here I am worrying about whether a Medicare Advantage plan should be helping me to buy a pair of sneakers, when the private corporations have overcharged Medicare by enough money to pay for at least a year of free dental care for all 28 million beneficiaries on Medicare Advantage. I would call that a massive policy toothache.

Al Norman has been writing opinion columns for the FiftyPlusLife since it first began publishing. He worked as executive director in the Massachusetts Home Care system for three decades.

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