Key Lawmakers Urge CMS to Curb Medicare Advantage Fraud, Abuse

McKnight’s Home Care | By Adam Healy
 
The Centers for Medicare & Medicaid Services should take swift action to “curb abusive practices” by Medicare Advantage plans, senators said in a letter sent Thursday. 
 
“The MA program is based on the premise that private insurance companies can and would administer Medicare coverage more cost-effectively — but it has failed to do so every single year,” Sens. Pramila Jayapal (D-WA) and Elizabeth Warren (D-MA) wrote in their letter. 
 
The Medicare Payment Advisory Commission has estimated that MA plans average receiving as much as 6% more per enrollee than traditional Medicare, the letter writers said. On top of that, MA plans also spend roughly 25% less on healthcare services per enrollee, they noted.
 
“It is imperative for CMS to rein in these abuses and protect Medicare coverage for
the seniors and people with disabilities who rely on it,” the senators wrote.
 
Jayapal and Warren recommended improvements in four areas. First, they advised CMS to augment base MA payments to offset overpayments due to favorable selection. Since MA beneficiaries are typically younger and healthier, they wrote, MA insurers may receive higher-than-average reimbursement from CMS while also paying out fewer claims, resulting in “gross overpayments.”
 
They also recommended CMS get more aggressive about recouping overpayments, implement a “network quality” measurement to MA plans’ star ratings, and limit insurers’ use of health risk assessments — which have been criticized for their lack of transparency.
 
Jayapal and Warren also noted MA plans’ use of artificial intelligence to “systematically deny care.” In November, UnitedHealthcare, the largest MA insurer, was alleged in a class action lawsuit to have used artificial intelligence tools to deny hundreds of patients post-acute care services, including home health.
 
Also on Thursday, CMS issued an extensive request for information seeking details about nearly all aspects of the MA program. They include care access data, prior authorization results, statistics related to patients’ outcomes and more. Still, Jayapal and Warren sought further enforcement action in their letter to the agency.
 
They gave qualified praise to steps CMS has already taken to limit overpayments.
 
Nonetheless, they noted, the Committee for a Responsible Federal Budget has projected that CMS will overpay MA insurers by as much as $1.56 trillion over the next decade. 
 
“As enrollment in MA continues to grow, CMS must take more aggressive action to ensure Medicare’s sustainability, protect taxpayer dollars, and curb abusive practices,” they said.