A report published Wednesday estimates that privately run, government-funded Medicare Advantage plans are overcharging U.S. taxpayers by up to $140 billion per year, a sum that could be used to completely eliminate Medicare Part B premiums or fully fund Medicare’s prescription drug program.
Physicians for a National Health Program (PNHP), an advocacy group that supports transitioning to a single-payer health insurance system, found that Medicare Advantage (MA) overbills the federal government by at least $88 billion per year, based on 2022 spending.
That lower-end estimate accounts for common MA practices such as upcoding, whereby diagnoses are piled onto a patient’s risk assessmentto make them appear sicker than they actually are, resulting in a larger payment from the federal government.
But when accounting for induced utilization — “the idea that people with supplemental coverage are likely to use more health care because their insurance pays for more of their cost” — PNHP estimated that the annual overbilling total could be as high as $140 billion.
“This is unconscionable, unsustainable, and in our current healthcare system, unremarkable,” says the new report. “Medicare Advantage is just another example of the endless greed of the insurance industry poisoning American healthcare, siphoning money from vulnerable patients while delaying and denying necessary and often lifesaving treatment.”
Even if the more conservative figure is accurate, PNHP noted, the excess funding that MA plans are receiving each year would be more than enough to expand traditional Medicare to cover dental, hearing, and vision. Traditional Medicare does not currently cover those benefits, which often leads patients to seek out supplemental coverage — or switch to an MA plan.
The Congressional Budget Office has estimated that adding dental, vision, and hearing to Medicare and Medicaid would cost just under $84 billion in the most costly year of the expansion.
“While there is obvious reason to fix these issues in MA and to expand traditional Medicare for the sake of all beneficiaries,” the new report states, “the deep structural problems with our healthcare system will only be fixed when we achieve improved Medicare for All.”
Bolstered by taxpayer subsidies, Medicare Advantage has seen explosive growth since its creation in 2003 even as it has come under fire for fraud, denying necessary care, and other abuses. Today, nearly 32 million people are enrolled in MA plans — more than half of all eligible Medicare beneficiaries.
Earlier this year, the Biden administration took steps to crack down on MA overbilling, prompting howls of protest and a furious lobbying campaign by the industry’s major players, including UnitedHealth Group and Humana. Relenting to industry pressure, the Biden administration ultimately agreed to phase in its rule changes over a three-year period.
Leading MA providers have also faced backlash from lawmakers for handing their top executives massive pay packages while cutting corners on patient care and fighting reforms aimed at rooting out overbilling.
As PNHP’s new report explains, MA plans are paid by the federal government as if “their enrollees have the same health needs and require the same levels of spending as their traditional Medicare counterparts,” even though people who enroll in MA plans tend to be healthier — and thus have less expensive medical needs.
“There are several factors that potentially contribute to this phenomenon,” PNHP’s report notes. “Patients who are sicker and thus have more complicated care needs may be turned off by limited networks, the use of prior authorizations, and other care denial strategies in MA plans. By contrast, healthier patients may feel less concerned about restrictions on care and more attracted to common features of MA plans like $0 premiums and additional benefits (e.g. dental and vision coverage, gym memberships, etc.). Insurers can also use strategies such as targeted advertising to reach the patients most favorable to their profit margins.”
A KFF investigation published last month found that television ads for Medicare Advantage “comprised more than 85% of all airings for the open enrollment period for 2023.”
“TV ads for Medicare Advantage often showed images of a government-issued Medicare card or urged viewers to call a ‘Medicare’ hotline other than the official 1-800-Medicare hotline,” KFF noted, a practice that has previously drawn scrutiny from the U.S. Senate and federal regulators.
PNHP’s report comes days after Cigna, a major MA provider, agreed to pay $172 million to settle allegations that it submitted false patient diagnosis data to the federal government in an attempt to receive a larger payment.
Dr. Ed Weisbart, PNHP’s national board secretary, told The Lever on Wednesday that such overpayments are “going directly into the profit lines of the Medicare Advantage companies without any additional health value.”
“If seniors understood that the $165 coming out of their monthly Social Security checks was going essentially dollar for dollar into profiteering of Medicare Advantage, they would and should be angry about that,” said Weisbart. “We think that we pay premiums to fund Medicare. The only reason we have to do that is because we’re letting Medicare Advantage take that money from us.”
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