The $20 Billion Scam At The Heart Of Medicare Advantage

[douglas9]

The health insurance behemoth Humana enjoyed a banner 2022. The Louisville, Ky.-based insurer made $2.8 billion in profits last year, while paying out $448 million in dividends to shareholders and more than $17 million in compensation to its CEO.

The main driver of those earnings? The federal government spent $20.5 billion overpaying Humana and other private insurers for the Medicare Advantage plans they manage on behalf of seniors and people with disabilities. If not for those overpayments, Humana could have suffered a nearly $900 million loss in 2022, according to a Lever analysis.

Humana is the most prominent example of how insurers have built a major cash cow out of systematically overbilling Medicare Advantage, the private Medicare program operated by private interests. These overpayments are symptomatic of a broader profit-driven policy agenda that seeks to completely privatize Medicare, one of the nation’s most popular social programs, and lock program recipients into subpar private insurance plans, even when they get sicker and need the best care possible.

Medicare Advantage plans have higher claim denial rates and more prior authorization restrictions than traditional Medicare plans. Last year, regulators found that nearly one in five payment requests rejected by Medicare Advantage plans in 2018 were wrongfully denied, representing an estimated 1.5 million claims.

https://www.levernews.com/the-20-billion-scam-at-the-heart-of-medicare-advantage/

[dalton99a]

1. Kick

[barbaraann]

2. Greed is insatiable. n/t

[Casady1]

3. The minute I could get away

from the thieves I did. Horrible awful people.

[MurrayDelph]

8. Me, too

After 40 years of having to get approval to see a specialist, only to find out the first referral wasn't in network or I'd have to wait months, or having to shop for an in-Network provider while on vacation, there was no way I was going to do it when retired, if I had a choice (I got laid off at 57 and survived on savings and Obamacare). So when I turned 65 I went with a MediGap. It's not perfect, but it's better than everything else available.

[Casady1]

14. My daughter had to have her lower jaw

moved back or by forty should have lost all her teeth. When you move the jaw back you lose your chin. If we asked them to pay to fix the jaw and move it back they would have denied everything. I had to pay the reconstruction out of pocket.
My wife has cancer and with the supplement it has been wonderful. They are evil people along with the republicans. These are the same assholes we fought in the sixties.

[louis-t]

4. That's why there are commercials 24/7.

Haven't seen a commercial for soap in about 5 years.

[yonder]

6. Good observation.

Most folks probably use soap and other day-to-day products in some form. One would think there would be tons of ads trying to sell one brand over the other. Those products probably aren't the cash cow that insurance (all kinds), pharmaceuticals, massive p.u. trucks, etc. are.

Our culture has been hijacked for the buck by the bucksters.

[erronis]

9. I got rid of the T.V. about 10 years ago. No ads in what I want to watch streaming.

But I agree that the cash cows of pharmaceuticals and insurance can outbid any retail product for placement.

Anytime you see a lot of money spent on advertising you know there's something fishy going on --- fishing into your wallet.

[FakeNoose]

17. Don't forget the robodialed phone calls - I probably get 10 per day

There needs to be a federal injunction against pairing the name "Medicare" with the word "Advantage."
The entire thing is a scam from the beginning.

[Earth-shine]

24. There are lot of commercials for laundry soap.

[louis-t]

39. Not on my tv.

I don't have cable. Antenna and streaming.

[Earth-shine]

40. I have no cable. I stream CNN and MSNBC.

There's laundry soap ads for Tide pods, Downy fabric softener, and more.

May you enjoy the go by using Charmin.

[Faux pas]

5. Kickin' with disgust!

[MichMan]

7. Why does the Federal government keep overpaying them?

[erronis]

10. Because they are underfunded and because the bureaucrats are bureaucrats.

CMS (Medicaid and Medicare) is a huge branch within the much huger HHS. They are only a "Center" but they are much more important that many departments with HHS.

CMS is also a target of repuglicons since they provide actual services to people (vs. money to lobbyists.) Their funding and staffing can't match the billions that are spent by the healthcare industry in legal fees, advertising, lobbying, etc.

And we also have individual states getting in the way of disbursing Medicaid money to their own needy people. Makes no sense, but that's how they operate.

[erronis]

11. Forgot to answer your actual question. Because the insurance companies present invalid claims.

I'm speaking mainly of Medicare Advantage (Part C) but also true for a fewer Part A and B.

It takes months/years to adjudicate claims within the system. For a CMS auditor to look at a whole set of claims from a particular insurance company already has this built-in delay. And the complexity of how claims are reported is ridiculous.

After finding an error in a set of claims submitted to CMS for repayment the process of rectifying and resolution and disputes often results in almost no action.

Kaiser Family Foundation (https://kff.org/) has a whole series on these problems.

[Wounded Bear]

12. When repubs cut funding for government agencies, by law they cannot cut benefits...

so cuts come from overhead, and most importantly from fraud investigations and enforcement.

[Ilsa]

13. My supplement has been set up for months, but I'm still getting

phones trying to sell me a Med Advantage plan.

[MOMFUDSKI]

15. I have Humana Advantage. Spine

surgery was $87K (on paper). I paid $88. Co-pay for day surgery in a hospital setting. I got a piece of mail from Humana asking me to call an 800 number. Automated voice asked if my surgery was due to an accident on someone’s property or a car accident or etc. to which I answered NO. That was all. Humana was looking to put the cost elsewhere, obviously. Can’t blame their lawyers. That is all.

[Demobrat]

19. MA plans are all about the network.

If the doctors and hospitals you need are in the network you’re in, you’re fine. Got a rare form of cancer and the specialist is not in your network? Go die.

Of course anyone who has private insurance through an employer knows about networks, pre-approvals, and claim denials. MA plans are the same thing - private insurance - offered to seniors as an alternative to traditional Medicare.

MA plans should not be allowed to use the word Medicare in the name. It is deliberately misleading. MA plans REPLACE traditional Medicare. I suppose there’s a reason that fact is never mentioned in the ads.

[OMGWTF]

16. Why are they allowed to use the name "Medicare" in their private for-big-profit scheme?

I have a traditional Medicare supplemental plan that costs about $200 a month, which is more than the so-called Advantage plans, but I know that they can't tell me, "Too bad, so sad, sucks to be you" if I ever need serious medical care.

[Demobrat]

20. Advantage plans can save you money

as long as you’re healthy.

[MichMan]

27. The government itself calls it "Medicare Part C" and has it available on their own website to enroll

I imagine that's why insurance companies can call it that because that it what it is called.

[LetMyPeopleVote]

18. I get numerous calls trying to get me to sign up for an advantage plan

The fact that someone is getting a commission or compensation for getting people to sign up for these plans tell me that this plans are sketchy

[Lonestarblue]

21. I have original Medicare and will never sign up for an Advantage plan.

Such plans now account for more than 50% of people who qualify for Medicare. Their goal is to wipe out original Medicare entirely, and then senior healthcare will be totally privatized with care being at the whim of insurance executives and their profits. I pay for dental and vision checkups, but I’d rather do that than see the insurance companies take over real Medicare.

[progree]

22. There is a bill to NOT allow private insurers to use the word Medicare in "Medicare Advantage"

https://pocan.house.gov/media-center/press-releases/pocan-khanna-introduce-bill-to-strengthen-medicare-define-alternative

Ahead of the Medicare Open Enrollment period, U.S. Representatives Mark Pocan (WI-02) and Ro Khanna (CA-17) are introducing the “Save Medicare Act” to rename so-called “Medicare Advantage” plans, prohibit private insurers from using “Medicare” in plan titles or advertisements, and impose significant fines for any insurer that engages in this deceptive practice.

“Only Medicare is Medicare. It is one of the most popular and important services the government provides,” Rep. Pocan said. “We should be working to expand this service to include coverage for dental, vision, and hearing care, as well as looking at ways to strengthen it rather than allowing these ‘Medicare Advantage’ programs to provide pale alternatives to what Medicare does. These non-Medicare plans run by private insurers undermine traditional Medicare. They often leave patients without the benefits they need while overcharging the federal government for corporate profit. This bill eliminates any confusion about what is – and what is not – Medicare, and ensures this essential program will continue to serve seniors and other Americans for years to come.”...

[markodochartaigh]

23. I see

Representatives Pocan and Khanna on Thom Hartmann answering questions from the public all the time. They are great.

[MichMan]

25. The Federal government itself calls it "Medicare Part C"

and allows people to enroll in them on the government website.

[progree]

30. The bill fixes that too

https://pocan.house.gov/sites/pocan.house.gov/files/Save%20Medicare%20Act.pdf

[MichMan]

31. Why not just make them illegal completely ?

No private insurance involvement at all in Medicare. Period

[progree]

33. Do we riverboat gamble? (which is what A and B alone is) Or change A and B to cover everything?

[MichMan]

36. I dunno; the OP says the taxpayers are being ripped off for $20 billion a year

Just changing the name doesn't appear to do much of anything substantial to address that

[progree]

37. And so....

Last edited Sun May 28, 2023, 10:47 AM - Edit history (1)

https://www.democraticunderground.com/1016352685#post35

[MichMan]

26. Eliminating Medicare Advantage and Medicare Gap programs should be a focus of the 2024 election

[progree]

28. Medicare Gap plans? Eliminate and replace with ?

Eliminating Medicare Advantage and Medicare Gap programs should be a focus of the 2024 election.

Without either, there is only parts A and B. A has its limitations and B covers only 80% -- the 20% is too much for old people who get very sick. To just rely on A and B as they are today is riverboat gambling.

[MichMan]

29. Nearly every post here wants private insurers to have no part in Medicare period

The OP call it a scam and that the government is being ripped off by them

[progree]

32. The difference with Medicare Supplement aka Medigap is there are much stricter rules

compared to MA, and no networks.

And the Medigap plans fill in what parts A and B don't cover, rather than replace the whole thing. Parts A and B still cover what they do now.

Its true though, that yes, Medigap plans, like MA plans, are all private insurers.

[MichMan]

34. Aren't providers of Medigap plans still raking in millions in profits from them?

Otherwise why would they all offer them?

[progree]

35. I GET THAT. What are you proposing we do? Expand A & B to cover everything, rather than in B's

case just the first 80%?

[anciano]

38. IMO there should be an out of pocket cap

for original Medicare just like there is for Medicare Advantage and Obamacare plans. That would help tremendously.