A bipartisan group of U.S. senators are calling for Medicare Advantage (MA) plan providers to improve transparency by reporting how much they are actually paying for patient services and how much patients are paying.
The group — Sens. Elizabeth Warren (D-MA), Catherine Cortez Masto (D-NV), Bill Cassidy (R-LA) and Marsha Blackburn (R-TN) — sent a letter on December 7 to the Center for Medicare and Medicaid Services regarding "shortfalls" in the agency's data collection and reporting practices for MA plans. The letter comes on the heels of a new bill the group introduced last month that seeks to help shore up those shortfalls.
In their letter, the group said there are “concerning trends" in MA including prior authorization and payment denials that actually met Medicare coverage rules.
Sign up for Kiplinger’s Free E-Newsletters
Profit and prosper with the best of expert advice on investing, taxes, retirement, personal finance and more - straight to your e-mail.
Profit and prosper with the best of expert advice - straight to your e-mail.
"Seniors in (Medicare Advantage) who use more services are more likely to disenroll from MA than healthier seniors," they said. Researchers have found that there are billions of dollars in overpayments to MA plans, "largely driven by favorable selection and shortcomings in the current risk adjustment model," they added.
The senators urged CMS to collect and publish a range of data including prior authorization requests, denials and appeals by type of service as well as justification of prior authorization denials. They also urged CMS to publicly issue data that it is already collecting, including out-of-pocket costs and provider payment information and plan comparison information.
The letter was sent on the same day that the Medicare open enrollment period ended.
New bill pushes for more details
Under their bill, the Encounter Data Enhancement Act introduced in November, the group is seeking to require MA plan providers to supply the government with details including the amount of cost sharing — such as deductibles, copayments and coinsurance — that is imposed for an item or service. Other requirements include details on the payment type from the plan to the provider — such as value-based, fee-for-service or capitation.
“American taxpayers are paying hundreds of billions of dollars for seniors to use Medicare Advantage plans, but the federal government still doesn’t know how much these plans are paying for patient services and how much patients are being forced to pay out-of-pocket,” said Cortez Masto (D-NV) in introducing the legislation.
“My bipartisan legislation will ensure these plans are transparent, helping us conduct appropriate oversight and provide seniors with the best possible health care coverage,” she added.
Medicare spending
In 2023, some $454 billion of federal Medicare spending went to MA, but the records kept by the private insurance companies often lack key information that is needed to combat fraud and abuse, the senators said. These companies are contracted with the federal government to provide coverage for over 30 million Americans, they said.
"While the federal government already requires Medicare Advantage plans to report encounter data on services provided to beneficiaries, these records are often incomplete or lack key information that is essential to combat fraud and abuse," they added.
The Senators said their legislation would:
- Provide researchers and policymakers with a much clearer understanding of plan payments to providers as well as how much patients are required to pay for services.
- Help lawmakers conduct oversight of federal dollars going to Medicare Advantage plans.
- Assess quality of care, and strengthen health care access for America’s seniors.
What to do if you missed open enrollment
If you missed Medicare open enrollment, there may be limited opportunities for original Medicare beneficiaries to make coverage changes, as Kiplinger recently reported. For those who are enrolled, note that premiums are up from 2023. It may be worth a look to see what you'll pay for Medicare next year.
Related Content
-
Visa, Mastercard's Swipe Fee Settlement Might Save You Money, For NowThe limited-time agreement directly benefits merchants, which can potentially pass savings on to consumers.
-
New List Out On Medicare Part B Drugs Eligible for RebatesSome Medicare beneficiaries may pay lower coinsurance rates from April 1 to June 30 for the drugs, HHS says.
-
Use An iPhone? You May Be Hearing From A Class-Action Lawsuit GroupA handful of suits against the iPhone maker seek to crack down on everything from app store purchases to messaging.
-
Capital One/Discover: What's In Their Wallet For You?Push back on Capital One's planned merger with Discover is growing with one group of consumer advocates calling for a public hearing.
-
Lawmakers: Nix Social Security Offsets For Seniors In Student Loan DefaultOffsetting Social Security benefits to pay for defaulted student loans can be devastating for some beneficiaries, lawmakers say.
-
Stellantis Recalls 285K Vehicles Over Airbag ProblemsDefective airbag inflators on certain Chrysler and Dodge vehicles could rupture and cause injury or death, NHTSA says.
-
HHS Funding Secured As Major Government Shutdown AvoidedWith passage of the fiscal 2024 appropriations package, Medicare and Social Security are among the key agencies to receive funding through September 30.
-
State Farm To Exit Homeowner Renewal Policies in CaliforniaState Farm plans to send non-renewal notices to 72,000 home and apartment policyholders starting this July.
