Medicare Advantage Overpayments

Government Overpayments to Medicare Advantage Plans are a major problem.
CMS pays Medicare Advantage Plans per member based on a risk score. The more chronic conditions the person has, the larger the payments CMS makes to the Medicare Advantage Plan.
Medicare Advantage Plans may be overexaggerating how sick their members are in order to increase their payments from CMS.
The Department of Justice is currently suing Cigna and Elevance (Anthem) for such over exaggerations.
However there is a deeper problem... CMS itself has performed its own audits, but has not done so in 10 years. CMS identified $650M in overpayments and did nothing about them.
When the Kaiser Family Foundation (KFF) requested information on the audits, CMS refused. KFF had to sue CMS to obtain the audit information and it took 3 years for KFF to win the case.
Perhaps it is incompetence on the part of CMS or perhaps CMS does not want to reveal the audits or do anything about them due to political pressure.
Sources:
www.npr.org/se....
www.commonweal...
www.reuters.co...
www.fierceheal...
www.fierceheal...
www.opensecret...
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[@INJURYCOMP]

Actually, I have to say, that THIS video is in the top 10 of most informative and important videos on KZbin. Initially, I was a little unsettled by the board and writing and, honestly, was about to turn it off but it made perfect sense when you started to explain it. Thank you.

[@ahealthcarez]

Thank you for watching!

[@damaragreene8541]

I work in Quality and Risk Adjustment for UHC AARP and this was great information.

[@ahealthcarez]

Super! Thank you for watching.

[@user-bc8dn7gr4n]

As a healthcare fraud investigator, specializing in pharmacy benefits, I would have to say this is exactly why no one wants to audit pharmacy claims. Big three make spread on pharmacy claims, but additional phantom or abandoned claims (not picked up by patients but order by physicians) make Med Advantage patients look sicker. Which is why our healthcare system is sick. Great video as usual. Keep up the great work.

[@ahealthcarez]

What?! PBM paid on ordered meds… not filled?!? Unreal!! Thank you for watching.

[@sanadbenali6993]

Thanks Dr bricker

[@ahealthcarez]

Thank you for watching!!

[@MoctarElemine-zu4ob]

I don’t understand Why the government brother doing all these audits if they’re not going to hold this corrupt health insurance companies accountable for what they’ve been doing. It’s very sad

[@ahealthcarez]

Agreed. Thank you for watching.

[@MsLayila]

Your videos have been immensely helpful especially when searching to find out more info re: value based care. This video definitely ties in!

[@ahealthcarez]

Thank you for watching and for your feedback.

[@vardaanaashish6753]

Hi Dr. Bricker, thank you for another fantastic video. I watched your video on HEDIS, and would love to hear from you on the connections and incentive structures between HEDIS, CMS, CAHPS, CQMs, Star Ratings in the Medicare and Medicaid world. Hopefully it is a topic worthy of your analysis!

[@ahealthcarez]

Thank you for your suggestions.

[@INJURYCOMP]

That is why everyone who gets a Medicare Part C plan gets a visit, to their home. from a medical person from the Part C plan to "harvest" medical information/history. They will bill Medicare for things that happened to the enrollee years ago even if they aren't being actively treated for it. That information should be required to be sent to the enrollee. With traditional Insurance, we get an EOD so we know what the Insurance company is paying out. We know what the Doctor is billing. It should be required that Part C plans report what they are billing the Government in the enrollee's name.

[@ahealthcarez]

Thank you for sharing your thoughts.

[@daviddobies2993]

Unbelievable. Thanks informing us.

[@ahealthcarez]

Thank you for watching and for your comment.

[@drartithangudu]

Such a helpful video! What do you think transparency on CMS over payments to MA will mean for companies like Oak Street Health & Chen Med? Nothing since nothing will change?

[@ahealthcarez]

Great question. Yes. You are correct.

[@123fredv]

Hi Eric. Since Medicare, as I understand it, sets the payment rates using cost reports and medpar data, would there be a time when there won't be enough original medpar data because most of the beneficiaries will go over to MA?

[@ahealthcarez]

Good question. Unclear. Much of Medicare rate setting now is based on making small adjustments to previous rates. Thank you for watching.

[@CharlieYou-sz3gj]

that's why CMI reduces code intensity by 5.9%

[@ahealthcarez]

Good point. Likely variability in which plans up-code more than other. More targeted approach might be more helpful.

[@ofeliahawkins9272]

How can I apply to be auditor for Cms?

[@ahealthcarez]

I don’t know. Thank you for watching.

[@cheston7883]

ᑭᖇOᗰOᔕᗰ 🙂