HHS: Many Insurers Exaggerate the Health Conditions of Medicare Advantage Patients

HHS said that many Medicare Advantage plans wrongly inflated patient risk scores, costing the government billions. Although no insurers were specifically named, HHS researchers said it was evident that the practice of overbilling was occurring industry wide.

“This is clearly impacting what taxpayers are paying for Medicare Advantage, I think, not in a good way,” said David Wennberg, MD, MS, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

Many insurers had a high number of medical condition reports, including an unusual number of patients with diabetes complications. A Center for Public Integrity investigation, which conducted a similar analysis to HHS, also found that Medicare made an estimated $70 million in “improper” payments to Medicare Advantage plans from 2008-2013. Investigation into the overages found that many Medicare Advantage plans regularly exaggerated the conditions of their patients and how much it cost to treat them.

“Further policy changes will likely be necessary,” said HHS researchers.

However, some insurance companies are becoming more accountable for appropriate care. Texas-based Centene Superior HealthPlan, for instance, said they would take a more targeted approach to reimbursing providers for value-based diabetes care. Although many pay-for-performance reimbursement models have been established for primary care, few programs specifically target diabetes.

Centene Superior HealthPlan said it planned to collaborate with Health Care Incentives Institute in a “Bridges to Excellence” program that will give bonus payments to providers based on the quality of diabetes care they deliver. The program initially will include 2600 patients with diabetes.

“Paramount to Superior is ensuring that our members receive the highest standard of care,” said Superior HealthPlan chief medical officer David Harmon, MD, in a media release. “We hope to further encourage exemplary service from our network of doctors while also recognizing them for the excellent care they provide.”

Around the Web

HHS Report Finds Medicare Advantage Plans Exaggerate Members’ Diseases To Make More Money [Kaiser Health News]

Medicaid Plans See Need for Value-Based Diabetes Care [Healthcare Payer News]