Medicare Advantage plans face criticism at congressional hearing for denying care, overcharging

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel.

Witnesses sharply criticized the fast-growing health plans at a House Energy and Commerce subcommittee on oversight and investigations hearing, citing critical audits and other reports that described plans denying access to health care — particularly those with high rates of patients disenrolled in their last year of life, while likely in poor health and in need of more services.

U.S. Rep. Diana DeGette, D-Colo., who chairs the subcommittee, said seniors shouldn’t be “required to jump through numerous hoops” to gain access to care.

The watchdogs recommended imposing limits on home-based “health assessments,” saying these visits can inflate payments to plans without offering patients appropriate care.

They also called for the federal Centers for Medicare & Medicaid Services to revive a foundering audit program that’s more than a decade behind in recovering billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.

Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan refused a request for a computed tomography scan that “was medically necessary to exclude a life-threatening diagnosis” of an aneurysm.

The plan required patients to have an X-ray first to prove a CT scan was needed.

Bliss said seniors might “not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon of the Government Accountability Office, Congress’ watchdog arm, said seniors in their last year of life dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans.

Under original Medicare, patients can see any doctor they want, though they might need to buy a supplemental policy to cover gaps in coverage.

Medicare Advantage plans accept a set fee from the government for covering a person’s health care, might provide extra benefits such as dental care and cost less out-of-pocket, with the tradeoff that they limit the choice of medical providers.

Still, enrollment in Medicare Advantage plans more than doubled the past decade, reaching nearly 27 million people in 2021. That’s nearly half of all people on Medicare, a trend many experts predict will accelerate as more baby boomers retire.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress, said Medicare Advantage could lower costs and improve care but “is not meeting this potential.”

Absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program. Committee Republicans had invited administrator Chiquita Brooks-LaSure to testify. U.S. Rep. Cathy Rodgers, R-Wash., said she was “disappointed” CMS punted, calling it a “missed opportunity.”

CMS officials didn’t respond to a request for comment.

AHIP, which represents the health insurance industry, said in a written statement that Medicare Advantage plans “deliver better service, access to care and value for nearly 30 million seniors and people with disabilities and for American taxpayers.”

At the hearing, the watchdogs sharply criticized home visits, which have been controversial for years. Because Medicare Advantage pays higher rates for sicker patients, health plans can profit from making patients look sicker on paper than they are.

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Bliss said Medicare paid $2.6 billion in 2017 for diagnoses backed up only by the health assessments. She said 3.5 million members didn’t have any records of getting care for medical conditions diagnosed during those health assessment visits.

Though CMS didn’t appear at the hearing, officials clearly knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation.” Health plans were directed to send CMS medical records documenting the health status of each patient and to return payments when they couldn’t.

The results were disastrous, showing 35 of 37 plans picked to be audited had been overpaid, sometimes by thousands of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still hasn’t completed audits dating as far back as 2011 through which officials had expected to recover more than $600 million in overpayments for unverified diagnoses.

In September 2019, KHN sued CMS under the Freedom of Information Act to compel the agency to release audits from 2011, 2012, and 2013 that the agency said still aren’t finished. CMS is scheduled to release the audits later this year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.