Medicare Advantage is ripe for Comer’s oversight committee to investigate

May 11, 2023 5:40 am

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Congressman James Comer, of Kentucky’s 1st District and chairman of the House Oversight Committee, is much in the news these days. The oversight committee is supposed to ensure the efficiency, effectiveness and accountability of the federal government and all its agencies.  Comer has been investigating everything from Chinese money laundering to Hunter Biden’s laptop to the origin of Covid-19.  Those may, indeed, be serious concerns, but there is a domestic health care issue that requires urgent attention.

Kentucky health care advocates have asked Rep. Comer to look into an issue central to the nation’s health and financial wellbeing.  Private, for-profit Medicare Advantage (MA) plans are siphoning billions from the Medicare Trust Fund while they delay and deny care to seniors and the disabled.

The Centers for Medicare and Medicaid Services (CMS), the government agency that oversees Medicare, is also in dire need of a thorough investigation. From 2008 to 2023 Medicare Advantage insurers collected $124 billion in overpayments, according to the Medicare Payment Advisory Panel. As terrible as it is to think of profiteers ripping off Medicare funds, it’s even worse that these Advantage plans are cheating on the care they owe to the patients.

In April of 2022, the Office of the Inspector General (OIG) of Health and Human Services reported that Medicare Advantage Organizations (MAOs) sometimes delayed or denied beneficiaries’ access to services even though the request met Medicare coverage rules.

Moreover, the Inspector General noted that MAOs denied payment to physicians, hospitals and other providers for some services that met both Medicare coverage rules and MAO billing rules. The OIG concluded, “Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.”

Congress enacted into law these for-profit MA plans because proponents argued that they would save us money. The opposite is the reality. Medicare Advantage plans now control 48 percent of beneficiaries yet use 55% of the Medicare funds. They do this even though there is indisputable evidence that their covered population tends to be younger and healthier and caring for them should cost less than those in traditional Medicare.

The story gets worse.  California internist Harlan Levine, MD, asserts that Medicare Advantage is a disadvantage for cancer patients.  He cites a study that concludes: Cancer patients with MA (Medicare Advantage) who had their stomach or liver removed were 1.5 times more likely to die within the first month after surgery compared to their peers with traditional Medicare. And MA beneficiaries who had oncologic surgery on the pancreas were two times as likely to die within the first month.

One of the obvious reasons for such inferior results is that most Medicare Advantage plans bar access to the top cancer centers such as Sloan-Kettering or the Mayo Clinic.

A New York Times story of Oct. 8, 2022, entitled “The Cash Monster Was Insatiable: How Insurers Exploited Medicare for Billions,” reported: “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 above stories are examples of fraudulent and unethical “upcoding.” Taxpayer dollars are being used to overpay insurers who engage in such abusive practices. 

Since private Medicare Advantage vendors are being overpaid—all while preventing or delaying necessary care, or delivering inferior care, why are they allowed to continue do so with impunity?  In fact, why do Congress and CMS allow them to continue to participate in the Medicare program at all?

That’s why we are respectfully asking Rep. Comer to hold a hearing, do an investigation, fulfill the oversight committee’s purpose, and put an end to the abuse of our seniors, the disabled and the public treasury. On April 22, 2023, we wrote to him asking for help in this struggle to stop the plunder of Medicare and protect it from privatization.

We are awaiting his response.

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Kay Tillow
Kay Tillow

Kay Tillow is a retired health care union leader and current activist in the movement for single-payer health care. She was born in Paducah and lives in Louisville.