Medicare Advantage Fraud In Plain Sight

Blog#198- 4/20/24

MEDICARE ADVANTAGE
FRAUD IN PLAIN SIGHT
By Richard Davis

The federal government may be finally realizing just how fraudulent the insurers are who provide Medicare Advantage policies. According to the Physicians for a National Health Plan (PNHP)”… federal administrators stood by their initial 3.7% increase, sending a message to corporate insurers that the Medicare Advantage gravy train may finally be slowing down.”

That would be something close to miraculous considering that many Advantage insurers have been found to be acting fraudulently and that most studies indicate that the Advantage program is draining money from the Medicare program at an alarming rate.

Five of the top 10 Advantage insurers have been accused of fraud by whistleblowers as well as the federal government.

Even if they are convicted, whatever fines they have to pay would simply be chalked up as the price of doing business because their profits from this program are so high.

It is estimated that by next year more than half of all Medicare beneficiaries will be in an Advantage program. The insurers reap giant profits when people sign up and they lure them in with low or no premiums, free gym memberships and all kinds of perks. But when the enrollees get sick they find out that many of their claims are denied and they often end up paying thousands of dollars more than they would have paid if they stayed in a traditional Medicare plan.

If current trends continue and people do not understand how they are undermining the entire Medicare program when they enroll in an Advantage plan, this country’s Medicare program will eventually be completely in the hands of the private insurance industry. Just ask any unhappy Advantage enrollee how bad things can get when they have to fight the big boys for cancer care or for drugs while they are suffering and dying. Those kinds of fights rarely happen in traditional Medicare programs.

Educating seniors about the difference between the two plans is more critical now than it has ever been because the feds may actually start listening to unhappy seniors as the government number crunchers realize just how much the private insurance industry is robbing all of us to maximize their profits.

Insurers have learned how to game the system and make big bucks. Consider this from a recent New York Times article. “The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck. Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again. Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.”

The Times notes that the government now spends as much on the Advantage program as the entire budget of the Army and Navy combined. Advantage insurers are spending as much time in court trying to defend their fraudulent practices as Donald Trump. This has to end and the only way that can happen is if the current 29 million Advantage beneficiaries jump ship and move back to traditional Medicare during the open enrollment period and if newly eligible seniors learn to keep away from the Advantage vultures.