Government watchdogs say Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year.
Erin Bliss, assistant inspector general at the Department of Health and Human Services; Leslie Gordon, acting director for health care at the Government Accountability Office; and James Mathews, executive director of the Medicare Payment Advisory Commission, an independent congressional agency, testified Tuesday before the House Energy and Commerce Subcommittee on Oversight and Investigations.
Bliss says seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”
The witnesses cited audits and other reports that described Medicare Advantage plans denying access to health care — especially plans with high rates of patients who were disenrolled in their last year of life while likely in poor health and in need of more services.
The witnesses recommended setting limits on home-based “health assessments,” which have been controversial for years, according to KHN.
Because Medicare Advantage pays higher rates for sicker patients, health plans can profit from making patients appear sicker on paper than they are. Bliss says Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments. But she says 3.5 million members didn’t have any records of getting care for medical conditions diagnosed during those health assessment visits.
And the watchdogs called for the Centers for Medicare and Medicaid Services to revive a foundering audit program that's more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies. CMS declined to send a witness to the hearing.
In 2007, CMS rolled out an audit effort directing health plans to send CMS medical records that documented the health status of each patient and to return payments when they couldn’t.
The results were disastrous, says KHN. Of 37 plans picked for audit, 35 had been overpaid, sometimes by thousands of dollars per patient.
CMS still hasn't completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.
KHN sued CMS under the Freedom of Information Act in 2019 to compel the agency to release audits from 2011, 2012 and 2013 — audits the agency says still aren’t finished.