I’ll Need To Tread Carefully Here

The Committee For A Responsible Budget posted this article, titled “Reducing Medicare Advantage Overpayments (click here).”

On one hand:

  • Medicare Advantage (and all health insurance) carriers are taking a notable amount of risk if your healthcare requirements are enormous, and the reason is that you have an annual out-of-pocket maximum limit. If you meet this, then the carrier is required to 100%, and it will not matter if your costs are $1 billion, you get the point.

  • The extra services are there, in part, to reduce your need for healthcare services because you are in better health.

On the other hand:

  • If a carrier states that you are in poor health, it gets paid more $ from the federal government for your situation.

  • If the plan has a higher star rating, it can get more $ per policyholder.

  • It is very difficult to prove that the carrier is not correct, so the obvious incentive exists to wrongly overstate the severity of your health situation.

  • Carriers and healthcare service providers can be the same owner, and so the motivation is to save money for you…and themselves, to increase profits.

I had a simple solution, no one is listening and it is my opinion only: eliminate upcoding entirely, and if a carrier is found to be guilty of systematic upcoding, moth ball the carrier forever.