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.