'Reigning In Waste, Fraud, & Abuse': Doggett Backs Cassidy's Push To End Medicare Advantage Upcoding

5 months ago

During a House Ways and Means Committee hearing in July, Rep. Lloyd Doggett (D-TX) spoke about Sen. Bill Cassidy's (R-LA) push to end the practice among Medicare Advantage providers known as "upcoding" when they inflate their risk assessment of the insured.

Transcript

00:00Mr. Doggett, you're recognized.

00:02Thank you very much, Mr. Chairman.

00:05You know, while the MA ads that are direct to consumer to seek new enrollees are usually misleading,

00:11the Medicare Advantage ads that are resisting reform are truly deceptive.

00:15A good example are those that are being run now over a million dollars' worth in the state of Louisiana

00:21against its senator, Republican Senator Dr. Cassidy,

00:25claiming that his efforts to end upcoding represent deep Medicare cuts for the people of Louisiana

00:31that will deny access to their doctors.

00:34Dr. Fiedler, can you explain why reining in waste fraud and abuse in Medicare Advantage can actually benefit all enrollees,

00:43including even those that are in MA plans, without in any way jeopardizing access to their healthcare

00:49as these false ads have been claiming against Senator Cassidy?

00:54As you mentioned, we're currently paying Medicare Advantage plans tens of billions dollars more per year

01:04than it would cost to serve the same beneficiaries in traditional Medicare.

01:09And so, if policymakers were to rationalize the MA payment system and use those funds to invest in the base Medicare benefit,

01:17that approach would obviously benefit traditional Medicare enrollees,

01:20but reinvesting the savings in those ways could benefit Medicare Advantage enrollees as well,

01:24because MA plans are required to cover the base Medicare benefit,

01:27because traditional Medicare is the competition for MA plans,

01:30and because those higher benefits would translate into higher benchmarks for MA plans.

01:34And because the MA plan is so inefficient, the MA status quo is so inefficient,

01:39depending on the circumstances and the design of that type of policy,

01:42even MA enrollees could end up better off on that than they are under the status quo.

01:48Well, thank you very much, and I'm sorry to say I hear the same kind of false ads are being run

01:52against Chairman Schweikert out in Arizona that have been used in Louisiana and elsewhere,

01:58when we could be working together to try to get the taxpayers more for their investment.

02:03Let me ask you to turn to the whole issue of risk adjustment,

02:07because after being promoted as a way to save taxpayer money and improve quality,

02:12we're still waiting to get the first cost benefits from Medicare Advantage,

02:17and in fact we've spent billions more than traditional Medicare.

02:20I have repeatedly urged CMS to rein in the abuse of upgrading,

02:26the very one that they're running these ads against people who raise that question.

02:31What are the benefits of adopting some new risk adjustment formula,

02:36such as I believe it's called DESE, that has been recommended by MedPAC.

02:40How would it impact good actors that don't engage in up coding?

02:45So I think the evidence is quite clear that CMS's existing methods

02:51for adjusting for higher coding intensity and Medicare Advantage are serious.

02:55are seriously inadequate, and that that's a big reason why payments to MA plans

02:59have ended up so much higher than intended.

03:03If CMS were to adopt a better method for adjusting for coding intensity,

03:07and I think MedPAC's and the research community's DESE method

03:12could be the foundation of a method for doing so,

03:16that would help mitigate this type of problem.

03:19I think that method could be used in one of two ways.

03:23It could be used to calculate insurer-specific adjustments,

03:26or it could be used to calculate adjustments at the market level.

03:29I think the advantage of insurer-specific adjustments is that it would only adjust coding intensity

03:35to the extent that a particular insurer plan is engaged in more intensive coding activity.

03:41I think a caveat with an insurer-specific approach is it could expand the scope for plans

03:46to engage in favorable selection.

03:48So I think there are trade-offs with these types of approaches.

03:51Finally, I'd ask you to turn to supplemental benefits.

03:54You know, when the enrollment period begins and we start seeing one ad after another on television,

04:00you get the impression you get free rent, free visits, free groceries,

04:04perhaps even a free autographed football from Joe Namath.

04:07But in fact, there are some limits on supplemental benefits.

04:13And I wonder if you could tell us a little more about your – just expand on your testimony

04:20concerning whether Medicare Advantage plans are adding significant value through these supplemental benefits,

04:26a number of which, when they relate, for example, to dental service,

04:30or the very type that some of us have been trying to get added to traditional Medicare.

04:36So I think the reality is when we're talking about particularly dental services,

04:41the coverage that MA plans are actually offering is often much more limited than, you know,

04:48what people expect to be covered under a dental plan in terms of either what services are covered

04:52or what the financial limits on the coverage are.

04:56You know, there are – MA plans do offer additional cost-sharing protections,

05:02in some cases lower premiums.

05:04But I think the issue, from my perspective,

05:06is those additional benefits aren't commensurate with the additional money we are paying those plans.

05:11And so there are probably much better ways to deliver those additional benefits to Medicare beneficiaries

05:16than the sort of bank shot through higher MA payments that we're working with today.

05:21Thank you. Thank you, Mr. Chairman.

05:23Thank you. I now –

'Reigning In Waste, Fraud, & Abuse': Doggett Backs Cassidy's Push To End Medicare Advantage Upcoding

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