Medicare Advantage Overpayments
Bipartisan Battle Against Medicare Advantage Overpayments
A new bipartisan bill, the No Unreasonable Payments, Coding or Diagnoses for the Elderly Act, aims to address the issue of overpayments to Medicare Advantage (MA) plans. This controversial topic has been met with massive opposition, and the bill's creators, Sens. Bill Cassidy and Jeff Merkley, hope to combat the financial incentives that enable MA plans to exploit risk adjustment for higher Medicare payments.
Medicare Advantage (MA) plans are a popular alternative to traditional Medicare. Offered by private insurance companies, they cover hospital and medical services (Parts A and B) and often provide extra benefits like prescription drugs, dental, and vision care. These plans, regulated by the Centers for Medicare & Medicaid Services (CMS), must cover at least the same services as Original Medicare but may have different rules and costs. MA plans are funded by a combination of Medicare payments to the private insurers and beneficiary premiums. With over 30 million people enrolled, MA plans have become a significant part of the Medicare landscape.
Medicare's impending insolvency is a significant concern, with Cassidy emphasizing that the bill is a step towards preserving the positive aspects of the system while minimizing waste. Critics argue that MA plans inflate patient risk scores to make them appear sicker than they are, thereby receiving higher payments from Medicare. The bill proposes excluding diagnoses from chart reviews and health risk assessments when calculating patient risk scores, as these have become key sources of up-coding by MA plans.
Furthermore, the bill would allow the Centers for Medicare & Medicaid Services (CMS) to use two years of diagnostic data to develop a risk adjustment model instead of just one year. This change aims to provide a more comprehensive picture of patient health and risk factors, and ultimately, promote more accurate risk assessments. CMS would also be required to consider any differences in coding patterns between MA plans and providers under Medicare Parts A and B, with a focus on closing the gap between assessments for MA and traditional Medicare.
This legislation emerges in the midst of a heated dispute between CMS and MA insurers over new regulations affecting the popular program, which serves over 30 million beneficiaries. CMS proposed a 1% increase for MA plans and changes to the risk adjustment model, set to take effect in 2024. However, insurers countered with their own analyses, arguing that these changes would result in a 2.27% cut, considering other factors such as adjustments to star ratings.
The Center for Medicare Advocacy, which advocates for CMS to crack down on MA up-coding, believes that the bill may offer some help but that more action is needed. Executive Director Judith Stein asserts that the real solution is to return to the original goal of privatized Medicare plans – providing equivalent care at a lower per-person cost. Stein contends that this objective has failed, as MA plans continue to be paid more per beneficiary than traditional Medicare costs.
As the debate over Medicare Advantage up-coding continues to unfold, stakeholders on both sides of the issue will be closely monitoring the progress of this new legislation. Its potential to enact meaningful change and address the financial incentives that have contributed to the problem will be a critical factor in determining its success or failure.
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A Blood Test For Alzheimer’s
Roche and Eli Lily are teaming up to develop a blood test for diagnosing Alzheimer’s. We have discussed Alzheimer’s many times on Unmasking medicine and how difficult it is to treat. Another problem with the disease is the difficulty in diagnosing it without extensive testing. Diagnosing Alzheimer’s in its early stages remains tricky since the symptoms are often not extreme and overlap with many other neurodegenerative diseases.
There are some tests for diagnosing the disease but they need cerebrospinal fluid in order to work. Accessing cerebrospinal fluid requires an injection into the spinal cord which is more complicated than a blood draw. The new test will use plasma from blood to diagnose the disease making it more accessible to patients. Additionally current tests are meant to be used as a form of early diagnosis and then further confirmation with a PET scan. While the current test is meant to be used in the same way with the ultimate aim of eventually becoming a standalone test for a definitive diagnosis.
The test look for two proteins called pTau and APOE, pTau tends to build up in early stages of the disease and APOE is the most common genetic risk factor for Alzheimer’s. In its testing stages, the blood test will be used as a way to narrow down the number of patients who may potentially suffer from Alzherimer’s and select them for further testing like doing PET scans.
This is an important advancement in the field and the test has a breakthrough device designation from the FDA highlighting how important it can be in moving the field forward if successful. Over the next few years Roche and Eli Lily plan to see how the test works among patient populations to determine efficacy and hopefully review their data around 2025 for a final push to approval.
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Featured Fake News
Yeah, we’re not even going to spend time debunking this. Y’all probably already know what we’re going to say. You can just refer back to the previous times we wrote about this.
