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The CMS is poised to crack down further on health insurers in the Medicare Advantage program, according to new comments from a top agency official.

MA plans — which now cover more than half of Medicare beneficiaries — have faced rising criticism over care denials and access, along with improper coding practices that inflate the program’s cost.

“You will see CMS in the future be a much tougher payer and much tougher regulator to ensure that, for every beneficiary and taxpayer who pay more for it, the value is there, the service is there and beneficiaries have full information for the choices that they’re making,” CMS Deputy Administrator Jon Blum said Thursday at the National Association of ACOs’ fall conference in Washington, D.C.

In MA, private health insurers receive lump sums from the government to cover the care of Medicare seniors. In exchange for this flexibility, MA payers can offer additional benefits, such as dental coverage or gym stipends.

As the popularity of MA plans grows, watchdogs and patient advocates have aired increasing concerns about access in the program. Earlier this summer, Congress held a hearing on MA claims denials, with witnesses testifying that MA plans frequently delay or deny care that would be covered under traditional Medicare.

Although the majority of requests for services are approved, it’s not uncommon for private MA plans to wrongly deny medically necessary care that would be covered under traditional Medicare, according to an HHS Office of Inspector General report from last April.

“We see in some markets a plethora of new benefits being offered that are not covered by the statutory Medicare program. But then we hear a lot of friction about beneficiaries not getting access to the core services they’re entitled to,” Blum said Thursday.

The CMS has take some action to try and ensure MA plans are providing required benefits. Earlier this year, the Biden administration finalized a rule reiterating that MA plans are required to comply with coverage rules in traditional Medicare.

MA payers have also been criticized for alleged profiteering in the program.

Overpayments to MA plans could reach more than $75 billion this year, due to favorable beneficiary selection, aggressive coding and quality bonus engineering, according to the USC Schaeffer Center for Health Policy and Economics.

A number of healthcare companies have been sued or shelled out fines to settle allegations of fraud and abuse in MA over the past few years, including CignaSutter Health and Kaiser Permanente.

Early this year, the CMS began to crack down on overpayments, planning to claw back billions of dollars to MA plans. The agency included risk adjustment changes in its proposed MA payment rule, but ultimately decided to phase in those updates over three years. 

Humana, one of the largest providers of MA plans in the country, sued the HHS in September, arguing the regulation is illegal and should be vacated.

Despite the regulations, some health policy experts have called on the CMS to take a tougher stance on MA oversight — something Blum signaled the agency is considering, especially given MA’s rising cost.

“We have a program that is growing quickly, that is being paid quite well and has a lot of flexibilities to provide more benefits to beneficiaries. So the tough questions that our teams are really putting out into the marketplace are, does it make sense for us to pay more per person to go into the MA program? How do we think about that value?” Blum said.


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