This kind of reminds me of when Medicare started  Diagnosis Related Group reimbursement in the early 80’s https://www.medicareadvantage.com/coverage/diagnosis-related-group  basically what it was… that Medicare decided to reimburse hospitals a fix $$$ on a pt when they were admitted to a hospital.  What it meant was that when a pt was admitted to a hospital the  medical reason for admission had a $$$ figure attached to that health issue and if the hospital was able to treat the pt and spend less than the $$$ allowed – they made money – and if they spent more than the $$ allowed – they LOST MONEY…  It was claimed that pts were being DISCHARGED QUICKER AND SICKER before the DRG reimbursement system was implemented.

Medicare Advantage Fraud Cases Pile Up; COVID Origins Settled? Nurse’s Murder Trial

https://www.medpagetoday.com/special-reports/features/101184

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Medicare Advantage Is Being Exploited for Big Profits

Major health insurers are exploiting the Medicare Advantage program to “inflate their profits by billions of dollars,” the New York Times reported, citing their review of dozens of fraud lawsuits, inspector general audits, and investigations by watchdogs.

By 2023, more than half of Medicare beneficiaries are expected to have a private Medicare Advantage plan, according to the Times. Although Medicare Advantage was meant to encourage better care at lower costs and to improve upon the traditional program, it has become more costly.

“The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients,” the Times reporters wrote. “And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.”

In response, most of the largest Medicare Advantage insurers contested the allegations, and have said that federal audits have been subpar. They have also said their goal has been to improve care by accurately describing patients’ health.

“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” Sen. Charles Grassley (R-Iowa), who has investigated the industry, said, according to the Times. He added that abuses of the program, such as making patients look sicker than they are, have “resulted in billions of dollars in improper payments.”

Many of the fraud lawsuits have been brought by former health insurers’ employees, and most have been joined by the Department of Justice. However, regulators at CMS have been more lax.

“Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care,” the Times reporters noted.

Filed under: General Problems