HS 171 SJSU Medicare Advantage & Federal Government Discussion

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HS 171

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Please write the overall evaluation and interpretation of the ideas presented in this paper for 2 pages.

TOPIC : Have Medicare Advantage plans overcharged the federal government?

https://khn.org/news/medicare-advantage-overbills-taxpayers-by-billions-a- year-as-feds-struggle-to-stop-it/

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TOPIC​ ​Have Medicare Advantage plans overcharged the federal government? https://khn.org/news/medicare-advantage-overbills-taxpayers-by-billions-a- year-as-feds-struggle-to-stop-it/ You can submit an individual paper or group paper. You can work with any or all members of your assigned group. You cannot work with another class member who is not in your assigned group. If a group paper is submitted, every person in the group will receive the same grade. If an individual paper is submitted, the individual will receive a separate grade, specific to their individual paper. Format of Research Paper: 5-7 pages 1.​ ​Introduction: 1-2 pages 2.​ ​Analysis: Explore your assigned topic and how it relates to issues we have discussed in class this semester. 2-3 pages 3.​ ​Discussion: 2 pages 4.​ ​References: no limit. Guidelines Introduction​: State your assigned topic. Provide a brief introduction of the topic and its relevance to managed care or managed care organizations. Analysis:​ Please address all of the following elements, not necessarily in this order: ·​ ​Explore the assigned topic in detail. Build an argument/analysis using specific references that are sourced. ·​ ​Make explicit reference to managed care and/or managed care organizations, and the principles that guide them, based on what you’ve learned in the course. ·​ ​Explore sources of information ​in addition to​ the “suggested starting reference” provided along with your assigned topic. Discussion​: Overall evaluation and interpretation of the ideas presented in your paper. Grading Criteria (75 points): 1.​ ​Introduction [15 points] 2.​ ​Analysis, including the use of sources to support specific claims. [35 points] 3.​ ​Discussion and Summary/Conclusion. [15 points] 4.​ ​Grammar, spelling, subtitles, APA format, and other format considerations [10 points] Introduction ​On July 30, 1965, Medicare was enacted by President Lyndon B. Johnson (History, 2019). It is a federal program in the United States designed to provide health insurance coverage to Americans 65 years old and older. Seven years later, the program expanded to Americans under 65 years old to those who with disabilities and anyone with permanent kidney failure requiring dialysis or transplant. There are four parts to Medicare: A, B, C, and D. Part A covers hospital insurance and Part B covers medical services. These two parts are referred to as the Original Medicare. Part C, also known as Medicare Advantage (MA), includes Original Medicare and additional benefits. Lastly, Part D covers prescription drugs. Medicare Part A is mandatory for beneficiaries, and the rest of the parts are voluntary. MA was created when the Balanced Budget Act was passed in 1997 (Mcguire, Newhouse, & Sinaiko, 2011). The purpose of the BBA was to expand managed care organizations under Medicare and reduce Medicare spending. This allowed Medicare beneficiaries to have the option to enroll in a health plan that is managed by private insurance companies and also controlled by the government. The Original Medicare is a covered benefit for MA plans. In addition, some MA plans offer benefits that are not included in the Original Medicare, such as prescription drugs, vision care, and dental care (Mcguire, Newhouse, & Sinaiko, 2011). Last year, there were 22 million Medicare beneficiaries who registered for MA plans (Jacobson, Freed, Damico, & Neuman, 2019). Recently, there has been an occurring problem of Medicare fraud and abuse in the United States. Medicare fraud is an illegal act when health insurers knowingly submit false statements in order to receive personal benefits from the federal government (Centers for Medicare & Medicaid Services, 2019). This includes billing services that the beneficiary did not receive or billing their diagnosis at a higher level. Medicare abuse can also occur, which is an unethical practice that involves billing unnecessary services. Health insurers may abuse billing codes on claims by upcoding a medical procedure or treatment. In the MA plans, the federal government pays health insurers based on the patient’s health status, which is calculated by using the “risk score” formula (Schulte & Weber, 2019). Health insurers will receive higher payments from the federal government for sicker patients compared to those who are healthy. However, health insurers had taken advantage of this to submit false billing claims. As a result, health insurers found a strategy to increase the patient’s risk score by exaggerating the patient’s sickness and condition, which led to the federal government overpaying MA plans. Analysis: W.I.P The conversation behind MA plans are complex. In order to begin the conversation about MA plans, we must first understand that Medicare Part A, B, and D and their coverages. Part A covers hospitalization. Part B covers physician services, hospital care, mental healthcare, home health services, diagnostic procedures and durable medical equipment. Medicare Part D coverage is referring to Drug Benefits and Prescription Drug Plans. To be eligible for Part D you must first be enrolled in Part A and B due to Part B being private prescription drug plans and Medicare Advantage prescription drug plans. There are four types of MA plans that are approved for beneficiaries which are; Coordinated care plans (CCPs), Private fee for service plans (PFFS), Medical Savings Account plans (MSAs), and Group Retiree Plans. MA plans are quite complex as they are paid by the Centers for Medicare and Medicaid Services (CMS) through a process called bidding (Kongstvedt, 2016). This bidding process determines the amount enrollees pay in premiums and how much cost sharing for Part A and Part B covered enrollees. The structure of these calculations is based on five categories. Which is Benchmark or base payment, Risk adjustments based on individual conditions (risk scores), the quality bonus payment, rebates, and premiums charged to enrollees. (Kongstvedt, 2016). Through this bidding process Medicare Advantage plans were able to overcharge Medicare by $30 billion in the past three years ​Schulte, F., & Weber, L. (2019). ​This bidding has allowed Medicare Advantage plans to exaggerate how ill their patients are in order to overcharge the government. This was to signify to Medicare that the Medicare Advantage insurance plan was treating patients with serious medical conditions. This evaluation of risk scoring was approved by congress in 2003. This was approved to incentivize insurance organizations to cover patients who would require more utilization for cost of services than usual. Today Medicare Advantage plans cover more than 22 million seniors (​Schulte, F., & Weber, L. (2019). ​For example, Essence Healthcare Inc. was one of the culprits in exaggerating patients’ medical conditions. Even though this was a small bump in the road of exploiting the government for insurance claims seeing how Essence had to refund $158,904 in overcharges that were administered to its patients ​Schulte, F., & Weber, L. (2019). Managed care under MA essentially offloads work that traditionally would be fulfilled by Medicare. This means that the non-profit focus of Medicare is lost as MA plans are allowed to be marketed and sold to individual Medicare beneficiaries. Health insurers seek to recuperate these marketing funds by utilizing billing abuses and mistakes under MA which have gone without audit. Recently the Centers for Medicare & Medicaid (CMS) are proposing a series of audits to return $1 billion of MA overpayments by 2020 at the same time as the Department of Health and Human Services (HHS) Inspector General’s Office launching a separate nationwide audit of MA (Schulte & Weber, 2019). With so much money tied up in this debacle, CMS is investigating the abuse of risk scores which are used to formulate the paid rate. CMS has already conducted 90 enhanced audits for payments made in 2011, 2012, and 2013; these audits are expected to collect $650 million in extrapolated penalties which is a huge escalation from previous audits collecting about $14 million (Schulte & Weber, 2019). Saving taxpayer money is a crucial aspect of this issue as MA plans are entrusted with the care of millions of adults. Payments for MA plans have increased between 2008 and 2018, from 21% ($99 billion) to 32% ($232 billion) and according to recent analysis; administrative expenses, including profits, accounted for 14% of MA plans (Cubanski, Neuman, & Free, 2019). Risk scores for MA patients have been rising without reason soon after its creation. Between 2007 and 2011, taxpayer costs have risen by more than $36 billion than standard Medicare, with more than 200 counties MA plans at least 25% higher than the costs of standard Medicare coverage (Schulte, Donald, & Durkin, 2015). Discussion and Summary References Centers for Medicare & Medicaid Services. (2019​). Medicare fraud and abuse: Prevent, detect, report ​[PDF]. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLN Products/Downloads/Fraud-Abuse-MLN4649244.pdf Cubanski, J., Neuman, T., & Freed, M. (2019, August 20). ​The facts on Medicare spending and financing​. Retrieved from https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/ History. (2019, July 30). ​President Johnson signs Medicare into law.​ Retrieved from https://www.history.com/this-day-in-history/johnson-signs-medicare-into-law Jacobson, G., Freed, M., Damico, A., & Neuman, T. (2019, June 6). A dozen facts about Medicare Advantage in 2019. Retrieved from https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-201 9/ Kongstvedt, P. (2016). ​Health insurance and managed care: What they are and how they work (Fourth ed.). Burlington, MA: Jones & Bartlett Learning. Mcguire, T. G., Newhouse, J. P., & Sinaiko, A. (2011). An economic history of Medicare Part C. Milbank Quarterly, 89(2), 289-331. https:/doi.org/10.1111/j.1468-0009.2011.00629.x Schulte, F., Donald, D., & Durking, E. (2015, January 14). ​Why Medicare advantage costs taxpayers billions more than it should. R ​ etrieved from https://publicintegrity.org/health/why-medicare-advantage-costs-taxpayers-billions-morethan-it-should/ Schulte, F., & Weber, L. (2019). ​Insurers running Medicare Advantage plans overbill taxpayers by billions as feds struggle to stop it.​ Retrieved from https://khn.org/news/medicare-advantage-overbills-taxpayers-by-billions-a-year-as-feds-s truggle-to-stop-it/
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Running Head: OVERBILLING OF MEDICARE
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Overbilling of Medicare
Student's Name
Institutional Affiliation

OVERBILLING OF MEDICARE

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The federal government is facing the significant challenge of correcting the overbilling of
medical bills of seniors by the Medicare health insurers. Billions of dollars are lost through the
Medicare plans with exaggerations of patient's sicknesses or treatment of rare severe conditions
that patients do not have. The federal officials are aware of all these, but their hope of regaining
some of the lost money is based on long-delayed plans. There have been efforts to remedy the
plans, but there are many drawbacks. Some of the federal officials are involved in the business of
health insurance related to Medicare, creating a conflict of in...


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