Congress should crack down on Medicare Advantage Health plans for the elderly that sometimes deny patients vital medical care while charging the government billions of dollars extra each year, government watchdogs told a House panel on Tuesday.
Witnesses at the hearing, held by the Energy and Commerce Subcommittee on Supervision and Investigation, sharply criticized the fast-growing health plan. They cited a number of critical audits and other reports describing plans to deny access to healthcare, especially to high-rate patients who were denied the last year of their lives when they were probably in poor health and needed more services.
Subcommittee Chair Rep. Seniors “have to jump through a lot of hoops” to get healthcare, says Diana Diggett (D-Colo.).
Watchdogs have recommended limiting home-based “health assessments,” arguing that these visits may artificially fund plans without proper patient care. They also called for the revival of a founding audit program for Medicare and Medicaid services or CMS centers that are more than a decade behind in recovering billions of additional payments on health plans, run by most private insurance companies.
Regarding the denial of treatment, Erin Bliss, assistant director general of the Department of Health and Human Services, said a Medicare Advantage Plan rejected a request for a computed tomography or CT scan that was “medically necessary to rule out life-threatening diagnoses (aneurysms).”
An X-ray must first be done to prove that patients in the health plan needed a CT scan.
Bliss said seniors “may not be aware that they may face more barriers to accessing certain types of healthcare services at Medicare Advantage than the original Medicare.”
Leslie Gordon of the Government Accountability Office, the Watchdog branch of Congress, said seniors have dropped out of the Medicare Advantage Plan at the rate of twice as many patients as in the last year of life.
Rep. Frank Pallon Jr. (DN.J.), chairman of the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients were facing “unwanted obstacles” to care.
Under the original Medicare, patients can see any doctor, although they may have to purchase a supplemental policy to fill the coverage gap.
Medicare Advantage plans charge a fixed fee from the government to cover an individual’s healthcare. Plans can provide additional benefits such as dental care and cost patients out of pocket, although they limit the choice of medical providers.
Excluding those trade-offs, Medicare Advantage is clearly proving attractive to consumers. Enrollment has more than doubled in the last decade, reaching nearly 27 million people in 2021. That’s about half of all people at Medicare, a trend many experts predict will accelerate as baby boomers retire.
James Matthews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could reduce costs and improve medical services but “does not meet this possibility” despite widespread acceptance among seniors.
Significantly absent from the hearing witness list was anyone from CMS, which runs the $ 350 billion-a-year program. The committee invited Republican CMS administrator Chikita Brooks-Lasur to testify, but the agency took a pass. Republican Kathy Rogers (R-Wash) says she pushed the “frustrated” CMS, calling it a “missed opportunity.”
CMS did not respond to a request for comment in a timely manner for publication.
AHIP, which represents the health insurance industry, issued a statement stating that the Medicare Advantage plan “provides better services, access to care and value for nearly 30 million seniors and people with disabilities and American taxpayers.”
At Tuesday’s hearing, both Republicans and Democrats stressed the need to improve the program while strongly supporting it. Nevertheless, the level of detail and criticism was unusual.
More generally, hundreds of members of Congress argued against the cut in Medicare Advantage and cited its growing popularity.
At the hearing, Watchdogs harshly criticized the home visit, which has been controversial for years. Since Medicare Advantage pays higher rates for sick patients, health plans can benefit patients to look sicker than them on paper. Bliss said Medicare paid $ 2.6 billion in 2017 for diagnostics backed up by health assessments alone; He said 3.5 million members had no record of caring for a medical condition diagnosed during that health assessment visit.
Although the CMS chose not to attend the hearing, officials knew a few years ago that some health plans were abusing the payment system to maximize profits, but continued to run the program for years in what a CMS official called an “honor system.”
CMS’s goal was to change things starting in 2007, when it launched an audit plan called “Risk Adjustment Data Validation” or RADV. Health plans were instructed to send CMS medical records that document the health status of each patient and pay when they cannot.
The results were disastrous, showing that 35 of the 37 plans selected for the audit were overpaid, sometimes thousands of dollars per patient. Common conditions that have been exaggerated or not verified range from chronic complications with diabetes to major depression.
Yet CMS has not yet completed the 2011 audit, through which officials expected to recover more than $ 600 million for additional payments due to undiagnosed diagnoses.
In September 2019, KHN filed a lawsuit against CMS under the Freedom of Information Act forcing the agency to publish audits of 2011, 2012 and 2013 – the agency claiming that the audits were not yet complete. CMS is scheduled to publish the audit later this year.
Contact us Submit a story tip