A government case alleging fraud by Kaiser suggests the profit motive may be encouraging health plans to cheat
Pfizer and Moderna will rake in the big bucks from their COVID vaccines. That’s a sign of a broken system.
, Medicare overpaid Medicare Advantage providers $14.1 billion, primarily because of “unsupported diagnoses.”in rejecting Sutter Health’s motion to dismiss the case against it, “Medicare Advantage organizations ... have some incentive to improperly inflate their enrollees’ capitation rates, if these organizations fall prey to greed.”
Several factors could account for the apparent explosion in fraud allegations in Medicare. One is the federal False Claims Act, which Congress upgraded in 1986 to ensure whistleblowers of a sizable share of recoveries from cheating government contractors — up to about 25% in cases in which the government participated as a plaintiff, and 30% if they pursued claims on their own.
It should be clear that health plans have two main ways to maximize their Medicare Advantage profits — by cutting costs, or increasing risk-adjustment payments. “You could have a patient with minor depression who’s suddenly upcoded to major depression,” Inman told me. “You see prevalence rates for some conditions that are not consistent with what you would expect to see in the general population. We were seeing cases of malnutrition that you weren’t expecting to see anywhere outside sub-Saharan Africa.”
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