Chithunzichi chikuwonetsa zithunzi zinayi zolekanitsidwa ndi mipiringidzo.  Chithunzi choyamba ndi chandalama ndi khadi la Medicare, chachiwiri ndi cha bambo wachikulire atakhala pampando, chachitatu ndi ndalama zapafupi, ndipo chachinayi ndi cha spreadsheet yamalipiro opitilira $8 miliyoni.

Medicare Advantage Plans Overcharged Medicare, Ndemanga Zimasonyeza: The Shots

Eric Harklerod/KHN/Getty Images/Unsplash/Centers for Medicare & Medicaid Services Data

Chithunzichi chikuwonetsa zithunzi zinayi zolekanitsidwa ndi mipiringidzo.  Chithunzi choyamba ndi chandalama ndi khadi la Medicare, chachiwiri ndi cha bambo wachikulire atakhala pampando, chachitatu ndi ndalama zapafupi, ndipo chachinayi ndi cha spreadsheet yamalipiro opitilira $8 miliyoni.

Eric Harklerod/KHN/Getty Images/Unsplash/Centers for Medicare & Medicaid Services Data

Zofufuza zomwe zangotulutsidwa kumene ku federal zimavumbulutsa kuchuluka kwa ndalama zolipiritsa komanso zolakwika zina zamapulani azaumoyo a Medicare Advantage, ndi mapulani ena akulipiritsa boma ndi ndalama zoposa $1,000 pa wodwala pachaka pafupifupi.

Chidule cha ma audition 90, omwe adasanthula ma invoice kuyambira 2011 mpaka 2013 ndipo ndi zosintha zaposachedwa zomwe zamalizidwa, zidapezedwa ndi KHN kudzera pamlandu wazaka zitatu wa Freedom of Information Act, womwe udathetsedwa kumapeto kwa Seputembala.

Ndemanga zaboma zidawulula pafupifupi $ 12 miliyoni pazolipira zochulukirapo pakusamalira odwala 18,090, ngakhale kuti zotayika zenizeni kwa omwe amakhoma msonkho zikuyenera kukhala zambiri. Medicare Advantage, njira yomwe ikukula mwachangu ku Medicare yoyambirira, imayendetsedwa ndi makampani akuluakulu a inshuwaransi.

Akuluakulu a Centers for Medicare and Medicaid Services ati akufuna kubweza ndalama zolakwa kuchokera pazitsanzozo pa umembala wonse wa pulaniyo – ndikubweza ndalama zokwana $650 miliyoni kuchokera kwa inshuwaransi.

Koma pafupifupi zaka khumi pambuyo pake, zimenezo sizinachitikebe. CMS ikuyenera kuwulula lamulo lomaliza pa Novembara 1, koma posachedwa idachedwetsa chigamulochi mpaka February.

Ted Doolittle, yemwe kale anali wachiwiri kwa mkulu wa CMS ‘Center for Program Integrity, yomwe imayang’anira zoyesayesa za Medicare polimbana ndi chinyengo chamalipiro ndi nkhanza, adati bungweli linalephera kuyankha mapulani a Medicare Advantage. “Ndikuganiza kuti CMS idachitapo kanthu pa izi,” adatero Doolittle, yemwe tsopano ndi wothandizira zaumoyo ku Connecticut.

CMS ikuwoneka ngati “yonyamula madzi” kumakampani a inshuwaransi, adatero Doolittle, zomwe “zimapanga ndalama” kuchokera ku mapulani a Medicare Advantage. “Kunja kumanunkha,” adatero.

Poyankha pa imelo ku mafunso olembedwa ndi KHN, wachiwiri kwa director wa CMS, Dara Corrigan, adati bungweli silinauze mapulani azaumoyo kuti ali ndi ngongole zingati chifukwa kuwerengerako “sanamalizidwe.”

Corrigan anakana kunena kuti bungweli limaliza liti ntchito yake. “Tili ndi udindo wovomerezeka komanso wovomerezeka wothana ndi zolipira zosayenera pamapulogalamu athu onse,” adatero.

Kulembetsa mu mapulani a Medicare Advantage kwawonjezeka kawiri pazaka khumi zapitazi

Zofufuza za 90 ndizo zokha zomwe CMS yamaliza zaka khumi zapitazi, yomwe ndi nthawi yomwe Medicare Advantage yakula kwambiri. Kulembetsa m’mapulaniwo kwachulukira kuwirikiza kawiri panthawiyo, kudutsa 28 miliyoni mu 2022, zomwe zidawononga boma $427 biliyoni.

Makumi makumi asanu ndi awiri mphambu limodzi mwa kafukufuku 90 adavumbulutsa ndalama zochulukirapo, zomwe zidaposa $1,000 pa wodwala pa avareji pakuwunika 23, malinga ndi mbiri ya boma. Malinga ndi zolembedwa, Humana, m’modzi mwa othandizira akulu a Medicare Advantage, adalipira ndalama zoposa $1,000 pa avareji pa 10 mwa zowerengera 11.

CMS idalipira mapulani otsalawo pang’ono kwambiri, kuyambira $8 mpaka $773 pa wodwala.

Kodi kubweza ndalama zambiri kumatanthauza chiyani?

Ofufuza amatchula za malipiro ochulukirapo pamene zolemba za wodwala zikulephera kulemba kuti munthuyo ali ndi vuto lachipatala lomwe boma linalipira kuti athetse ndondomeko ya zaumoyo, kapena ngati akatswiri a zachipatala akuwona kuti matendawa ndi ovuta kwambiri kuposa momwe amanenera.

Zinachitika pafupifupi pafupifupi 20% ya milandu yachipatala yomwe inayesedwa m’zaka zitatu; Matenda omwe sanatsimikizidwe anali apamwamba muzolinga zina.

Pamene Medicare Advantage yakula kwambiri pakati pa okalamba, CMS yavutika kuti isunge ndondomeko zake zowerengera ndalama, ndipo kuwonongeka kwakukulu kwa boma kwachepetsedwa kwambiri.

Njirayi yakhumudwitsa makampani onsewa, omwe adawonetsa kuti kafukufukuyu ndi “wolakwika kwambiri” ndipo akuyembekeza kuti atha kuwongolera, komanso oyimira Medicare, omwe akuwopa kuti ma inshuwaransi ena atha kulanda boma.

“Pamapeto pa tsiku, ndalama za okhometsa msonkho zimagwiritsidwa ntchito,” atero a David Lipshutz, loya wamkulu wa ndondomeko ku Medicare Support Center. “Anthu akuyenera kudziwa zambiri za izi.”

Pafupifupi maphwando atatu, kuphatikiza a KHN, adasumira CMS pansi pa Freedom of Information Act kuti achotse zidziwitso zabodza zokhudzana ndi kubweza kwake, zomwe CMS imatcha Risk Adjustment Endorsement, kapena RADV.

KHN idasumira CMS mu Seputembara 2019 bungweli litalephera kuyankha pempho la FOIA loti aunike. Pamgwirizanowu, a CMS adavomera kupereka zikalata zowerengera ndi zikalata zina ndikulipira $ 63,000 kwa Davis Wright Tremaine, kampani yazamalamulo yomwe idayimira KHN. CMS sinavomereze kuti zolemba zidabisidwa molakwika.

Ma inshuwaransi ena nthawi zambiri amanena kuti odwala anali odwala kuposa pafupifupi, popanda umboni woyenerera

Mapulani ambiri omwe adawunikidwa amagwera mu zomwe CMS imachitcha “gulu lapamwamba la coding density”. Izi zikutanthawuza kuti iwo anali m’gulu la anthu ovuta kwambiri kufunafuna malipiro owonjezera kwa odwala omwe amati anali odwala kuposa pafupifupi. Boma likukankhira mapulani azaumoyo pogwiritsa ntchito njira yotchedwa “Risk score” yomwe ikuyenera kupereka mitengo yokwera kwa odwala omwe akudwala komanso kutsika kwa odwala athanzi kwambiri.

Koma nthawi zambiri, zolemba zamankhwala zoperekedwa ndi mapulani azaumoyo zimalephera kuchirikiza zonenazi. Milandu yosachirikizidwa idayambira ku matenda a shuga mpaka kulephera kwa mtima.

Ponseponse, kubweza kwapakati pazolinga zaumoyo kuyambira $ 10 mpaka $ 5,888 pa wodwala aliyense wotengedwa ndi Touchstone Health HMO, dongosolo laumoyo ku New York lomwe lidathetsedwa ndi “kuvomerezana” mu 2015, malinga ndi zolemba za CMS.

Makampani awiri akuluakulu a inshuwaransi omwe adakweza chindapusa cha Medicare, malinga ndi kafukufuku: United Healthcare ndi Humana

Mapulani ambiri azaumoyo omwe adawunikidwa ali ndi mamembala 10,000 kapena kupitilira apo, zomwe zimawonjezera kuchuluka kwamalipiro ochulukirapo pamene mitengo ikuwonjezeka. UnitedHealthcare ndi Humana, mabungwe awiri akuluakulu a inshuwaransi a Medicare Advantage, adawerengera 26 mwa 90 zofufuza za mgwirizano pazaka zitatu.

Pazonse, zowerengera za 90 zidapeza mapulani omwe adalandira $22.5 miliyoni pakubweza, ngakhale zolipirazo zidafanana ndi kulipira pang’ono kwa $ 10.5 miliyoni.

Ofufuza amayang’ana makontrakitala 30 pachaka, chitsanzo chaching’ono cha makontrakitala 1,000 a Medicare Advantage m’dziko lonselo.

Kafukufuku 8 wa mapulani a UnitedHealthcare adapeza ndalama zochulukirapo, pomwe ena asanu ndi awiri adapeza kuti boma lidalipira zochepa kwambiri.

Mneneri wa UnitedHealthcare Heather Soule adati kampaniyo ilandila “kuyang’anira pulogalamu yoperekedwa ndi RADV Audits.” Koma adati kafukufukuyu akuyenera kufananiza Medicare Benefit ndi Original Medicare kuti apereke “chithunzi chonse” chamalipiro opitilira muyeso. “Zaka zitatu zapitazo tidapanga malingaliro ku CMS kuti azichita kafukufuku wa RADV pa pulani iliyonse, chaka chilichonse,” adatero Soule.

Kafukufuku wolipidwa ndi Humana 11 adaphatikizanso mapulani ku Florida ndi Puerto Rico omwe CMS idawunikira kawiri pazaka zitatu.

Dongosolo la Florida Humana linalinso chandamale cha kuwunika kosagwirizana mu Epulo 2021 ndi Inspector General of Health and Human Services. Kufufuza kumeneku, komwe kunakhudza zolipiritsa mu 2015, kunatsimikiza kuti Humana adasonkhanitsa molakwika pafupifupi $200 miliyoni chaka chimenecho poganizira momwe odwala ena adadwala pa mapulani ake a Medicare Advantage. Akuluakulu sanapezebe ndalama zonsezo.

Mu imelo, mneneri wa Humana a Jahna Lindsay-Jones adatcha zotsatira za kafukufuku wa CMS “zoyambirira” ndipo adanenanso kuti zidatengera zitsanzo zakale.

“Ngakhale tidakali ndi nkhawa za momwe kafukufuku wa CMS amachitira, Humana akupitirizabe kugwira ntchito limodzi ndi olamulira kuti apititse patsogolo Medicare Advantage m’njira zomwe zimawonjezera mwayi wa okalamba kupeza chithandizo chapamwamba, chotsika mtengo,” adalemba.

Mabilu ali pachiwopsezo

Zotsatira za kafukufuku wa 90, mosasamala kanthu za msinkhu wawo, zikuwonetseratu zomwe zapezedwa posachedwa za malipoti ena a boma ndi milandu ya whistleblower – zambiri zomwe zinatulutsidwa chaka chatha – ponena kuti ndondomeko ya Medicare Advantage nthawi zambiri inkakweza ziwopsezo za odwala kuti awonjezere mtengo ku. boma, mabiliyoni a madola. dola.

Brian Murphy, katswiri wolemba zolemba zachipatala, adati palimodzi kuti ndemanga zikuwonetsa kuti vutoli likadali “lovuta kwambiri” kumakampani.

Ofufuza akupeza milandu yowonjezereka yofanana “mobwerezabwereza,” adatero, ndikuwonjezera, “Sindikuganiza kuti pali kuyang’anira kokwanira.”

Zikafika pakubweza ndalama kuchokera ku mapulani azaumoyo, kulowetsedwa ndiye chinthu chachikulu chomamatira.

Ngakhale kuti extrapolation imagwiritsidwa ntchito mobwerezabwereza ngati chida muzofufuza zambiri za Medicare, akuluakulu a CMS sanagwiritsepo ntchito ku Medicare Advantage audits chifukwa chotsutsidwa kwambiri ndi makampani a inshuwalansi.

“Ngakhale kuti detayi ndi yoposa zaka khumi, kafukufuku waposachedwapa akuwonetsa kuti Medicare Advantage ingakwanitse komanso kuyang’anira madola a Medicare,” anatero Mary Beth Donahue, pulezidenti wa Better Medicare Alliance, gulu lomwe limalimbikitsa Medicare Advantage. Anati makampani “akupereka chisamaliro chabwinoko komanso zotsatira zabwino” kwa odwala.

Koma otsutsa amatsutsa kuti CMS imangoyang’ana gawo laling’ono la mgwirizano wa Medicare Advantage m’dziko lonselo ndipo iyenera kuchita zambiri kuteteza madola amisonkho.

Doolittle, yemwe kale anali mkulu wa CMS, adati bungweli liyenera “kuyamba kutsatira nthawi ndikuchita kafukufukuyu pachaka ndikuwonjezera zotsatira.”

Koma a Cathy Bobbitt, loya wa zaumoyo ku Texas, adakayikira chilungamo chofuna kubweza ndalama zambiri kuchokera kumakampani a inshuwaransi patatha zaka zambiri. “Mapulani azaumoyo adzavutikira mano ndi misomali ndipo sizipangitsa kuti CMS ikhale yosavuta,” adatero.

KHN Kaiser Health News ndi nkhani yodziyimira pawokha yadziko lonse komanso pulogalamu KFF (Caesar Family Foundation).

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