Posts filed under ‘Fraud’

As We’ve Been Saying!

Finally, the Center’s long-time concerns about costly misuse of public Medicare funds may be gaining attention. For years we’ve been pointing to Medicare overpayments for prescription drugs and to private Medicare Advantage plans. These huge expenditures help pharmaceutical and insurance industries, not older and disabled people. If these costs were reigned in, billions of dollars would be freed to cover necessary health care and sustain the Medicare program. This week these matters received some much needed publicity:

Prescription Drug Pricing

An excellent and well-timed (given #Epi-gate) article appeared in this week’s Journal of the American Medical Association discussing the reason drug costs are so high in the U.S. According to the article, the major cause is the “granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a level not observed in other industrialized nations.” Thus, state the authors, “providing greater opportunities for meaningful price negotiation by governmental payers” is one of the conclusions. A “possible solution” is described as “Price negotiation: Enable Medicare to negotiate drug prices for individual Part D plans and to exclude coverage for expensive products that add limited clinical benefit; experiment with value-based drug pricing and rational prescribing reimbursement models for Medicare.” For more information, see http://jama.jamanetwork.com/article.aspx?articleid=2545691#.V8OQC8OH7Hg.twitter

Medicare Advantage Overpayments

NPR recently published an article from the Center for Public Integrity entitled “Medicare Advantage Audits Reveal Pervasive Overcharges” (August 29, 2016) by Fred Schulte. The article reports on recently-released federal audits of 37 Medicare Advantage (MA) plans relating to overpayments made in 2007. According to the author, these “audits reveal how some private Medicare plans overcharged the government for the majority of elderly patients they treated, often by overstating the severity of certain medical conditions, such as diabetes and depression.”
As discussed in previous Alerts, including one in May 2016 entitled “Government Auditor Finds Billions in Improper Payments to Medicare Advantage Plans Coupled with Inadequate Oversight by Federal Regulator,” MA “upcoding” – when an MA plan reports an enrollee as being more sick than they actually are in order to obtain a higher risk-adjusted payment from the Medicare program – remains a problem that policymakers must address, particularly as they weigh policy proposals that would shift additional costs on to Medicare beneficiaries.

August 31, 2016 at 9:45 pm Leave a comment

Stop Bleeding Medicare By Wasting Money on Private Plans

And we quote:

Private insurers’ Medicare Advantage plans cost Medicare an extra $34.1 billion in 2012
Instead of being more efficient, private insurers have cost Medicare almost $300 billion more over the life of the program

A study published online today finds that the private insurance companies that participate in Medicare under the Medicare Advantage program and its predecessors have cost the publicly funded program for the elderly and disabled an extra $282.6 billion since 1985, most of it over the past eight years. In 2012 alone, private insurers were overpaid $34.1 billion.
That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, the researchers say.
The findings appear in an article published in the International Journal of Health Services by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled “Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.”
Hellander is policy director at Physicians for a National Health Program (PNHP), a nonprofit research and advocacy group. Woolhandler and Himmelstein are professors at the City University of New York School of Public Health, visiting professors at Harvard Medical School and co-founders of PNHP.”

May 15, 2013 at 6:19 pm Leave a comment

Proposed Home Health Co-Pay is a Big Mistake

We have to say, Forbes has it right!  The co-pay for Medicare home health care proposed in the President’s budget is a big mistake.  It will not save money, will harm people with chronic conditions, and will increase avoidable hospitalizations.  It isn’t even a good tool for fighting fraud – if that is the goal.

Far from getting too much care, our experience is that thousands of people with multiple sclerosis, Parkinson’s disease, ALS, paralysis, and other long-term conditions, struggle to get the home care they DO need.  A little bit of nursing and/or therapy, along with hands-on health aide services, often means the difference between staying home and requiring a hospital stay or nursing home placement.  For most Medicare beneficiaries with chronic conditions, home health care is more humane, more effective and less expensive.

If fraud is the concern, fight it. Don’t add co-pays or other barriers for those who really do need home care and qualify for Medicare coverage.

April 22, 2013 at 2:56 pm Leave a comment


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