Protect Medicare And Stop Medicare Advantage Fraud And Profiteering

More than 62 million people across the country rely on Medicare for their health care, and nearly half of those recipients are enrolled in Medicare Advantage, an alternative to traditional Medicare coverage for seniors through private health insurance companies1. Funds from the traditional Medicare trust are used to pay the health insurance companies offering Medicare Advantage plans — and because these companies are private, their focus is ultimately on their bottom line.

The main issues: Fraud, Denial of Care & Profiteering

Medicare Advantage (MA) has a track record of predatory marketing. Their misleading and aggressive advertising is not totally honest about what plans cover and what is available locally. Much of the advertising conveniently leaves out that MA plans often have restricted provider pools, high deductibles, and many of the promised services are not locally available.

For those enrolled in Medicare Advantage, it can be difficult to get care without experiencing burdensome denials and delays. MA has a problematic pattern of denying upwards of 18% of all claims, even those that would be approved by traditional Medicare2. Medicare Advantage enrollees and their providers should not have to jump through more prior authorization hoops than traditional Medicare participants. And these excessive denials and delays impact providers’ participation in the program: there is a recent trend of rural hospitals no longer accepting Medicare Advantage insurance because of the burden of the preauthorization process and denials3. Losing rural providers would put many in the state at risk of losing access to care.

Finally, we need to address the rampant profiteering being committed by these companies. The Medicare program is nothing short of a lifeline for millions of Americans, and we know that its financial stability is more perilous than ever. Yet, insurance companies through MA are draining the trust fund by taking taxpayer money to pay their agents and brokers outrageous bonuses and fund their deceptive advertising (the ads alone are estimated to cost us $6-10 billion every year4) — some of these insurance companies are overcharging the government through various fraudulent means. For example, they have been submitting codes for patients’ conditions that are more severe than they were actually diagnosed in order to receive a higher reimbursement5. The current rules allow Medicare Advantage insurers to be compensated at a higher rate than traditional Medicare while not enforcing they meet the equivalent standard of care. The result: more money for crooked insurance companies while bleeding the Medicare trust fund dry.

CMS can fight back – with our help

The Center for Medicare & Medicaid Services is meant to regulate the program, but it has fallen short on responding to the insurance companies’ shameless money-grabbing. The agency has largely not enforced its existing rules, and changes have been slow and inadequate.

That’s why driving formal comments about this proposed change is so critical. If there is a public outcry for CMS to take more action, the agency will have to get aggressive on these companies: through regular audits, collection of overpayments, implementation of common-sense guardrails to prevent unnecessary denials, and punishment and removal of insurance companies that break the rules, including ending their contracts. This reform would do more than save money — eliminating the very worst of the MA plans would save lives by ensuring patients get the care they need when they need it.

 

The process to leave a public comment might seem intimidating, but we are ready to walk you through it! Here’s how:

  1. First, go to the Federal Register’s website, and click on the green box labeled “Submit a formal comment” on the right side of the page.
  2. Next, draft your comment in the text box. Keep in mind that the most impactful comment will be personal, so be sure to note if you or your loved ones are on or will soon be on Medicare. You can also share details specific to your state or community. Speaking from personal experience and concerns makes for an effective comment. (And if you need talking points and additional guidance on how to draft your comment, check out this resource from Indivisible OneNYS!)
  3. For the question “What is your comment about?”, choose “Private Industry – Health care” from the drop-down menu.
  4. Enter your email address.
  5. For the question “Tell us about yourself! I am…”, select “An Individual” with the megaphone icon.
  6. Finally, scroll down to fill in your contact information and submit your comment.

It’s time for CMS to be bold and hold the insurance companies accountable by cracking down on fraud and overpayments, ridding the program of bad actors, and providing quality healthcare as promised. Submit your comment today by the January 5, 2024 deadline, and invite your family, friends, and neighbors to join in.