As of 2017, a third (approximately 19 million) of all Medicare beneficiaries are now in the Medicare Advantage (MA) program, which is run by private insurers. The insurers receive payments from the federal government based on the sickliness of the population the plan insures, populations with more incidents of severe or chronic diseases lead to higher reimbursements. Insurers strive to keep patients healthy, and costs low, by coordinating their care through cost-conscious networks of doctors and hospitals.
However, some argue that MA plans are risky for seniors in declining health, especially those who see specialists. Those seniors often face obstacles when trying to access specialists. A recent GAO report presents data that gives these criticisms more weight than ever before. The report reviewed 126 MA plans and found that 35 of the plans have disproportionally high numbers of sicker people leaving the plan. Patients most often cited difficulty accessing “preferred doctors” or other medical care as the reason for leaving a plan. The report did not name the 35 plans, but noted that these statistics might be a sign of poor management or care. Twenty four MA plans saw 20% of their beneficiaries leave in 2014 alone.
A spokeswoman for America’s Health Insurance Plans (AHIP), the largest lobby representing the interests of insurers, responded to the GAO report saying that most people who leave an MA plan switch to a different MA plan that is better suited to them. She also pointed out that MA plans often offer benefits not covered by traditional Medicare, such as dental insurance and health club membership.
System-wide, CMS is increasing enforcement against health plans that deliver less than they promise. In January and February of this year, CMS has fined 10 MA plans over $4 million, alleging “delayed or denied access” to covered benefits. Whistleblower actions have also surfaced in enforcing MA plan’s promises. In May, Freedom Health, the owner of a Florida based MA plan settled an FCA suit for $32 million, partially for allegedly getting rid of patients who were costly to treat.
* * *If you would like more information or would like to speak to a member of Constantine Cannon’s whistleblower lawyer team, please click here.