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Fed war on health care spending abuse needs to include Medicare Advantage

Commentary: Obama administration bragging about anti-fraud efforts, but Center report showed bigger dollars are being lost elsewhere

By Wendell Potter
Center for Public Integrity, March 23, 2015

The Obama administration went to great lengths last week to inform us that it recovered $3.3 billion in fraudulent payments to Medicare health care providers in fiscal year 2014. Officials even went so far as to give an advance copy of their report to The Wall Street Journal, which, like the Center for Public Integrity, has been investigating Medicare fraud and abuse.

In a story that appeared in the Journal before the official release of the report, WSJ reporter Stephanie Armour wrote that the recovery “was part of an effort by the Obama administration to improve enforcement and prevent abusive billing practices.” That effort is run jointly by the Department of Health and Human Services the Justice Department.

HHS secretary Sylvia Burwell was quoted in the story as saying that “we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud,” an effort she said is helping to extend the life of the Medicare Trust Fund.

That’s good news, of course. Taxpayers benefit when doctors and other health care providers get caught trying to rip off the government.

But when it comes taking on big and well-connected insurance companies that have been ripping off the Medicare program for years, the administration has been far less aggressive in catching, much less punishing, the abusers.

As the Center for Public Integrity reported last week, officials in the Obama administration were advised as long ago as 2009 that a formula the government uses to pay private insurers that participate in the Medicare Advantage program “triggered widespread billing errors and overcharges” that waste billions of tax dollars every year.

There was no press release issued by the administration about that 2009 report; in fact, the administration buried it. The report probably never would have surfaced at all had the Center for Public Integrity not filed a Freedom of Information request seeking records going back several years regarding payments to Medicare Advantage plans.

The Medicare Advantage program is a privately run alternative to standard Medicare. Close to a third of Medicare-eligible Americans are now enrolled in insurance company-operated Medicare Advantage plans. People enrolled in these plans typically pay less out of pocket for their care—which explains their appeal—but also typically have a smaller network of providers to choose from.

As Center reporter Fred Schulte explained in his March 13 story, the federal government pays these private health plans a set monthly fee for each patient based on a formula known as a risk score. Risk scores were put in place by the government to measure the state of Medicare Advantage enrollees’ health. “Sicker patients merit higher rates than those in good health,” Schulte wrote.

Schulte’s investigation into risk score payments last year uncovered evidence that the government has been overpaying private insurers for years. That’s because the risk scores can be manipulated by insurers to make it appear that enrollees are sicker than they actually are. Just last week, the Government Accountability Office estimated that “improper payments” to Medicare Advantage plans totaled more than $12 billion in 2014 alone.

When Schulte came across the unpublished 2009 report, he asked CMS why it was never made public.

The explanation he got was preposterous. According to a CMS spokesperson, the agency wanted to publish the report but was told it was too long, that to be considered for publication on a government-run research site, it would have to be “substantially shortened.” This despite the fact that some of the reports that have been published on that site are even longer than the one on risk score manipulation.

The story gets even more incredible. The CMS spokesperson said that “given competing workload demands we were not able to revise and resubmit the article.”

I don’t doubt that the folks at CMS were especially busy in 2009. That’s the year debate began on what would eventually become Obamacare.

To make Obamacare work, the administration needed to have the support of the insurance industry. Insurers had to agree to change many of their profitable but anti-consumer practices in exchange for billions of dollars in new revenue from the government.

Insurance industry lobbyists are among the most powerful and well connected in Washington. Could the administration have put the kibosh on the 2009 report because it didn’t want to jeopardize its relationship with insurers and put the reform law at risk?

We’ll probably never know. But if the administration is really as serious about reducing Medicare fraud as it said last week it is, let’s hear more from CMS about what it’s doing to end abuses in the Medicare Advantage program.

The Wall Street Journal reported that the owners of a home health care company that defrauded the government were recently sentenced to prison terms of up to 120 months each. How much do you want to bet that executives of Medicare Advantage plans that are overbilling taxpayers out of far more money will ever see the inside of a jail cell?

Wendell Potter is the author of "Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care" and "Deceiving Americans and Obamacare: What’s in It for Me? What Everyone Needs to Know About the Affordable Care Act."

http://www.publicintegrity.org/2015/03/23/16942/fed-war-health-care-spending-abuse-needs-include-medicare-advantage