Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle To Stop It | Kaiser Health News

Medicare can’t manage its claims mainly because it relies on retroactive audits and is prevented by law, except in very limited cases, of doing prospective claim review and pre certification and approval. That’s why, despite lower fees, health care providers rather deal with Medicare than private insurers.

Medicare fraud and waste goes far beyond Medicare Advantage plans.

Let’s think about what this could mean if the Medicare claim processes applied to every Americans health care.

Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have. Getting refunds from the health plans has proved daunting, however.

Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Source: Insurers Running Medicare Advantage Plans Overbill Taxpayers By Billions As Feds Struggle To Stop It | Kaiser Health News


  1. Q, your statement that health care providers would rather deal with Medicare than private insurers despite lower fees is inaccurate and misleading. Yes, Medicare may in some instances be easier to deal with than some private insurers. But the lower fees provided by Medicare have led many health care providers to refuse to treat Medicare patients or at least to restrict the number of Medicare patients they treat.


    1. I disagree. The number of providers who do not participate in Medicare is quite small. I have asked staff in scores of physicians offices in NJ, Pa and Florida which insurer is easiest to deal with and everyone said Medicare because there is no pre-cert or questioning of claims whatsoever as opposed to what they go through with private insurers. Lower fees do not matter or are offset by the private section.


      1. I think that Medicare also offers a common set of rules and expectations in the sense that it is basically the same from Medicare patient to patient on what is allowed and what billing code to use. Now transfer that to the hundreds of possibilities for other insurance contracts provided by thousands of different employers. Even my old employer has different rules and co-insurance or co-pays depending or the date of hire, date of retirement, and which state you are in. Now throw in all the different private drug plans. I take it as just a shear numbers thing. There might be a few dozens variations of Medicare part B & D plans but after a while, I think a doctor’s office will learn the common things quite quickly. I think for the rest of the health insurance market, may be a doctor’s office only has one patient on one type of one BCBS plan and may not know what is required for that plan. Is pre-authorization required? Number of PT visits allowed for this injury.
        Which drugs are not covered, etc..


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