Medicare Advantage plans overcharged Medicare, audits show : Shots

Eric Harkleroad/KHN /Getty Images/ Unsplash/ Centers for Medicare & Medicaid Services Data

A photo illustration shows four images separated by bars. The first image is of money and a Medicare card, the second is an older man sitting in a chair, the third is a closeup of money, the fourth is of a spreadsheet of overpayments totaling over $8 million.

Eric Harkleroad/KHN /Getty Images/ Unsplash/ Centers for Medicare & Medicaid Services Data

Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans, with some plans overbilling the government more than $1,000 per patient a year on average.

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million from insurers as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but recently put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage plans. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

Enrollment in Medicare Advantage plans has more than doubled in the last decade

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

What constitutes an overpayment?

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the

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New Health Plans Offer Twists on Options, With a Dose of ‘Buyer Beware’ | Healthiest Communities Health News

Trendy-hunting websites guarantee convenience and freedom from networks, at far much less than the value of classic wellness insurance policies.

“Welcome to coverage that’s last but not least truthful,” says one particular, in bold lettering. “Just take treatment of your health with a person simple app,” suggests one more.

It really is all element of procuring for wellbeing protection in 2021.

When they are even now area of interest items, these nontraditional possibilities say they intention to soothe client aggravation with substantial premiums and deductibles by harnessing the growing availability of price data or patients’ newfound consolation with online well being services.

1 this sort of offering, from insurance provider Sidecar Well being, pays shoppers its approximated hard cash price tag for every single medical go to and lets them shop for the ideal deal. An additional, from Antidote Wellness, just isn’t insurance plan, but presents obtain to on-line-only principal care for a tiny regular monthly payment.

Still, these options arrive with a dose of “customer beware.”

Whilst the picture the designs present is one of people taking management of their wellbeing care expenditures, the “truth is probably the reverse,” explained Dania Palanker, assistant research professor at the Centre on Health and fitness Insurance Reforms at Georgetown College.

That is for the reason that they are not Cost-effective Treatment Act designs. They are not in depth health-related coverage, and could go away clients dependable for hundreds or even thousands of dollars, either for the reason that rewards address only aspect of a health-related invoice or since of other plan constraints.

What’s available by California-based Sidecar Well being and Antidote in New York may attractiveness to purchasers who are youthful or additional tech-savvy, the uninsured, or those who don’t get subsidies to help them obtain Very affordable Care Act ideas.

Buyers say ACA options are “too pricey, or the out-of-pocket fees are as well high,” or doctors never acknowledge them, mentioned Mike Smith, president of The Brokerage, a internet marketing organization in Texas that recruits insurance policies brokers and also sells insurance policies.

But these plans’ decreased rates are achievable, in portion, since the programs deal with much less than ACA ideas.

Regular benefits do not incorporate maternity treatment and there is certainly no once-a-year restrict on how considerably people can spend out of pocket – neither of which is authorized in an ACA system. Sidecar prospects might uncover the quantities reimbursed to them for treatment to be far considerably less than they are charged, even though Antidote won’t protect lab get the job done, X-rays, medical center treatment or pricey medication.

Sidecar’s Entry Plan, licensed for sale in 17 states, adds a layer of pricing information and facts to what’s known as fastened-indemnity plans. These types of plans pay the policyholder a flat level, commonly a dollar volume, centered on the style of care they obtain, such as a medical professional check out or a day in the healthcare facility.

Not like usual indemnity designs, Sidecar supplies

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Medicare Advantage plans’ ‘free’ dental, vision, hearing benefits come at a cost

When Teresa Nolan Barensfeld turned 65 last year, she quickly decided on a private Medicare Advantage plan to cover her health expenses.

Barensfeld, a freelance editor from Chatham, N.Y., liked that it covered her medications, while her local hospitals and her primary care doctor were in the plan’s network. It also had a modest $31 monthly premium.

She said it was a bonus that the plan included dental, hearing and vision benefits, which traditional Medicare does not.

But Barensfeld, who works as a copy editor, missed some of the important fine print about her plan. It covers a maximum of $500 annually for care from out-of-network dentists, including her longtime provider. That means getting one crown or tending to a couple of cavities could leave her footing most of the bill. She was circumspect about the cap on dental coverage, saying, “I don’t expect that much for a $31 plan.”

Through television, social media, newspapers and mailings, tens of millions of Medicare beneficiaries are being inundated this month — as they are each autumn during the open enrollment period — by marketing from Medicare Advantage plans touting low costs and benefits not found with traditional Medicare. Dental, vision and hearing coverage are among the most advertised benefits.

Those services are also at the center of heated negotiations on Capitol Hill among Democrats as they seek to expand a number of social programs. Progressives, led by Sen. Bernie Sanders (I-Vt.), are pressing to add dental, vision and hearing benefits to traditional Medicare.

Despite the high-powered advertising of the Medicare Advantage plans pitched by the likes of celebrities Joe Namath and Jimmie Walker, beneficiaries still generally end up with significant out-of-pocket costs for many of these services, a recent study by KFF found. That’s partly because the private plans limit benefits. While people in traditional Medicare paid on average about $992 for dental care in 2018, those in Medicare Advantage plans paid $766, according to the study. For vision, people with traditional Medicare paid $242, compared with $194 for those covered by a Medicare Advantage plan.

“It stands to reason there would be lower out-of-pocket spending in Medicare Advantage than in traditional Medicare, but the differences are not as large as one might expect,” said Tricia Neuman, a senior vice president at KFF and executive director of its Medicare policy program.

More than 26 million people were enrolled in Medicare Advantage plans for this year — 42% of all Medicare beneficiaries. Enrollment in the private plans has doubled since 2012 and tripled since 2007. Unlike traditional Medicare, these private plans generally allow coverage through a limited network of doctors, hospitals and pharmacies.

Open enrollment for 2022 plans runs from Oct. 15 to Dec. 7, and some Advantage plans offer enticements such as hundreds of dollars’ worth of groceries, home-delivered meals or $1,000 in over-the-counter items such as adhesive bandages and aspirin.

But many seniors don’t realize there are restrictions on these benefits. They may cover extras only for enrollees with certain

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Medicare plans, ‘free’ dental, vision, hearing benefits come at a cost

By Phil Galewitz | KHN


When Teresa Nolan Barensfeld turned 65 last year, she quickly decided on a private Medicare Advantage plan to cover her health expenses.

Barensfeld, a freelance editor from Chatham, New York, liked that it covered her medications, while her local hospitals and her primary care doctor were in the plan’s network. It also had a modest $31 monthly premium.

She said it was a bonus that the plan included dental, hearing and vision benefits, which traditional Medicare does not.

But Barensfeld, who works as a copy editor, missed some of the important fine print about her plan. It covers a maximum of $500 annually for care from out-of-network dentists, including her longtime provider. That means getting one crown or tending to a couple of cavities could leave her footing most of the bill. She was circumspect about the cap on dental coverage, saying, “I don’t expect that much for a $31 plan.”

Through television, social media, newspapers and mailings, tens of millions of Medicare beneficiaries are being inundated this month — as they are each autumn during the open enrollment period — by marketing from Medicare Advantage plans touting low costs and benefits not found with traditional Medicare. Dental, vision and hearing coverage are among the most advertised benefits.

Those services are also at the center of heated negotiations on Capitol Hill among Democrats as they seek to expand a number of social programs. Progressives, led by Sen. Bernie Sanders (I-Vt.), are pressing to add dental, vision and hearing benefits to traditional Medicare.

Despite the high-powered advertising of the Medicare Advantage plans pitched by the likes of celebrities Joe Namath and Jimmie Walker, beneficiaries still generally end up with significant out-of-pocket costs for many of these services, a recent study by KFF found. That’s partly because the private plans limit benefits. While people in traditional Medicare paid on average about $992 for dental care in 2018, those in Medicare Advantage plans paid $766, according to the study. For vision, people with traditional Medicare paid $242, compared with $194 for those covered by a Medicare Advantage plan.

“It stands to reason there would be lower out-of-pocket spending in Medicare Advantage than in traditional Medicare, but the differences are not as large as one might expect,” said Tricia Neuman, a senior vice president at KFF and executive director of its Medicare policy program.

More than 26 million people were enrolled in Medicare Advantage plans for this year — 42% of all Medicare beneficiaries. Enrollment in the private plans has doubled since 2012 and tripled since 2007. Unlike traditional Medicare, these private plans generally allow coverage through a limited network of doctors, hospitals and pharmacies.

Open enrollment for 2022 plans runs from Oct. 15 to Dec. 7, and some Advantage plans offer enticements such as hundreds of dollars’ worth of groceries, home-delivered meals or $1,000 in over-the-counter items such as adhesive bandages and aspirin.

But many seniors don’t realize there

Read More... Read More

Medicare Plans’ ‘Free’ Dental, Vision, Hearing Benefits Come at a Cost

When Teresa Nolan Barensfeld turned 65 last year, she quickly decided on a private Medicare Advantage plan to cover her health expenses.

Barensfeld, a freelance editor from Chatham, New York, liked that it covered her medications, while her local hospitals and her primary care doctor were in the plan’s network. It also had a modest $31 monthly premium.

She said it was a bonus that the plan included dental, hearing and vision benefits, which traditional Medicare does not.

But Barensfeld, who works as a copy editor, missed some of the important fine print about her plan. It covers a maximum of $500 annually for care from out-of-network dentists, including her longtime provider. That means getting one crown or tending to a couple of cavities could leave her footing most of the bill. She was circumspect about the cap on dental coverage, saying, “I don’t expect that much for a $31 plan.”

Through television, social media, newspapers and mailings, tens of millions of Medicare beneficiaries are being inundated this month — as they are each autumn during the open enrollment period — by marketing from Medicare Advantage plans touting low costs and benefits not found with traditional Medicare. Dental, vision and hearing coverage are among the most advertised benefits.

Those services are also at the center of heated negotiations on Capitol Hill among Democrats as they seek to expand a number of social programs. Progressives, led by Sen. Bernie Sanders (I-Vt.), are pressing to add dental, vision and hearing benefits to traditional Medicare.

Despite the high-powered advertising of the Medicare Advantage plans pitched by the likes of celebrities Joe Namath and Jimmie Walker, beneficiaries still generally end up with significant out-of-pocket costs for many of these services, a recent study by KFF found. That’s partly because the private plans limit benefits. While people in traditional Medicare paid on average about $992 for dental care in 2018, those in Medicare Advantage plans paid $766, according to the study. For vision, people with traditional Medicare paid $242, compared with $194 for those covered by a Medicare Advantage plan.

“It stands to reason there would be lower out-of-pocket spending in Medicare Advantage than in traditional Medicare, but the differences are not as large as one might expect,” said Tricia Neuman, a senior vice president at KFF and executive director of its Medicare policy program.

More than 26 million people were enrolled in Medicare Advantage plans for this year — 42% of all Medicare beneficiaries. Enrollment in the private plans has doubled since 2012 and tripled since 2007. Unlike traditional Medicare, these private plans generally allow coverage through a limited network of doctors, hospitals and pharmacies.

Open enrollment for 2022 plans runs from Oct. 15 to Dec. 7, and some Advantage plans offer enticements such as hundreds of dollars’ worth of groceries, home-delivered meals or $1,000 in over-the-counter items such as adhesive bandages and aspirin.

But many seniors don’t realize there are restrictions on these benefits. They may cover extras only for enrollees with

Read More... Read More

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