Insurers Accused of $50B Fraud Connected to Medicare Advantage Plans

Introduction

Private insurers who offer Medicare Advantage Plans for seniors covered under Medicare are accused of defrauding taxpayers to the tune of $50 billion between 2019 and 2021. This report from the Wall Street Journal shows that Medicare Advantage made “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments,” including for deadly illnesses where patients received no care and for conditions that “people couldn’t possibly have.”

What are Medicare Advantage Plans?

Medicare Advantage plans are private insurance policies offered to Medicare-eligible individuals for a premium. The plans are marketed as a way to expand the coverage of services available to seniors, and give them more options. However, the plans have been subject to scrutiny since their inception. This is due to the fact that coverage is largely determined by private insurers, who may deny necessary care while covering alternative therapies like acupuncture using a coordinated care reimbursement model.

The Cost of Enrollment

Despite being marketed as advantageous, the upfront cost to enroll in Medicare Advantage plans may not add up to additional value for many patients. The plans’ costs are largely determined by private insurers, and coverage is contingent on those insurer’s decisions. Further, the number of patients covered by these plans has gone up over time, and more than half of Medicare enrollees now utilize Advantage plans.

Insurer’s Accused of Fraudulent Activities

The Wall Street Journal’s report shows that some private insurers offering Medicare Advantage plans may have defrauded taxpayers for billions of dollars. This was done through hundreds of thousands of questionable diagnoses, leading to extra taxpayer-funded payments. Analysis of billions of Medicare records was used to discover the problematic diagnoses. Further, in some cases, neither the patient nor physicians were aware of any billing practices on the part of the insurers for the dubious services provided.

Impact of the Fraud

The overall impact of this fraud is far-reaching, as the amount of taxpayer dollars used to fund these fraudulent services could have been used to provide needed care to those actually suffering from the conditions. This in turn can cause a delay in potentially life-saving treatment for those who depend on Medicare coverage.

Alternative Medicines in Medicare

It is worth noting that, while alternative therapies like acupuncture are covered under some Medicare Advantage plans, they are generally not covered under traditional Medicare. Despite limited evidence to support alternative treatments, many seniors still choose to pursue these options due to the perceived benefits. It is important to stress that these alternative treatments should not be used as a substitute for medically necessary care or as a way to undermine the traditional healthcare industry.

Conclusion

The problem of fraud in Medicare Advantage plans not only affects taxpayers, but also seniors who rely on the system for their care. By increasing efforts to detect and punish fraudulent activities, stakeholders can work to ensure open and transparent coverage for all those relying on the Medicare system.

Originally Post From https://healthexec.com/topics/healthcare-management/healthcare-economics/insurers-accused-50b-fraud-connected-medicare-advantage-plans

Insurers accused of $50B fraud linked to Medicare Advantage plans