Senators Elizabeth Warren and Pramila Jayapal are urging the Centers for Medicare & Medicaid Services (CMS) to implement sweeping reforms in the Medicare Advantage program. In a letter to CMS Administrator Chiquita Brooks-LaSure, the lawmakers emphasize the need to address overpayments by proposing changes to base payments, tackling coding intensity discrepancies, and enhancing the quality bonus payment program. Despite disputes over methodologies, their advocacy aims to create a fairer, more accountable system that aligns with the broader goal of promoting quality healthcare services within Medicare Advantage. The call for comprehensive reforms signals a commitment to refining the program’s efficiency and fairness.
In a bid to address concerns surrounding overpayments within the Medicare Advantage program, two prominent lawmakers, Sen. Elizabeth Warren and Rep. Pramila Jayapal, are urging the Centers for Medicare & Medicaid Services (CMS) to take more decisive actions. The CMS is anticipated to release its 2025 rate notice to plans in the coming weeks, and lawmakers are calling for comprehensive reforms to curb overpayments. This article delves into the key issues raised by Senators Warren and Jayapal, exploring the proposed measures to reform base payments, address coding intensity, and enhance the quality bonus payment program.
Background:
The Medicare Advantage program, designed to provide additional benefits beyond traditional Medicare, has faced criticism for potential overpayments. A crucial concern highlighted by the lawmakers is the impact of favorable selection within the program. The Medicare Payment and Advisory Commission (MedPAC) has estimated that differences in enrollment patterns may lead to an excess payment of $34 billion to Medicare Advantage in 2024 compared to traditional Medicare.
Reforming Base Payments:
Senators Warren and Jayapal are advocating for fundamental changes to base payments within the Medicare Advantage program. They propose modifications to offset the impact of favorable selection, wherein beneficiaries with varying healthcare needs may choose or avoid Medicare Advantage based on perceptions of limited networks and potential delays in care. The suggested reforms aim to create a fairer payment structure reflective of the actual healthcare utilization patterns of beneficiaries.
Addressing Coding Intensity:
A significant component contributing to overpayments is the alleged upcoding practices, where healthcare providers manipulate codes to make patients appear sicker than they are. MedPAC estimates that differences in coding between Medicare Advantage and fee-for-service Medicare could result in $54 billion in overpayments to the program in 2024. To counter this, Senators Warren and Jayapal are pushing for a reduction in payments to account for coding intensity, aiming to rectify discrepancies and ensure accurate reimbursement.
Aggressive Collection of Overpayments:
In their letter to CMS Administrator Chiquita Brooks-LaSure, the lawmakers emphasize the need for more assertive measures in collecting overpayments. Allegations of upcoding have been pervasive across major payers, leading to settlements and legal actions. The Senators are urging CMS to strengthen its efforts in collecting overpayments, reinforcing financial accountability within the Medicare Advantage program.
Disputes and Criticisms:
Despite the call for reforms, the Better Medicare Alliance, a group backed by insurers, has disputed the methodologies employed by MedPAC in reaching its conclusions. The debate underscores the complexity of assessing overpayments and the need for a nuanced understanding of the various factors influencing payment differentials between Medicare Advantage and fee-for-service Medicare.
Quality Bonus Payment Program Reforms:
Warren and Jayapal are not solely focused on payment adjustments; they are also urging CMS to reform the quality bonus payment program. This program provides bonuses to plans that achieve a quality star rating of four or above. The lawmakers advocate for enhancements to ensure that the program effectively rewards high-quality care and incentivizes improvements in healthcare outcomes. This aligns with the broader goal of promoting quality healthcare services within the Medicare Advantage framework.
Enforcement Against Illegal Denial of Care:
In addition to addressing financial aspects, the lawmakers are calling for increased enforcement against plans that illegally deny care. This aspect is crucial in safeguarding beneficiaries’ rights and ensuring that Medicare Advantage plans adhere to legal and ethical standards in delivering healthcare services. The push for stronger enforcement reflects a commitment to protecting the interests of beneficiaries and maintaining the integrity of the Medicare Advantage program.
The push for comprehensive reforms in the Medicare Advantage program by Senators Warren and Jayapal signifies a commitment to rectifying systemic issues and promoting fairness. By targeting the root causes of overpayments, including favorable selection and coding intensity differences, lawmakers seek to establish a more transparent and accountable payment system. The call for aggressive collection of overpayments and enforcement against illegal denial of care underscores their dedication to protecting beneficiaries’ rights. As debates over methodologies persist, the senators’ multifaceted approach, encompassing financial adjustments and quality-related reforms, signifies a holistic effort to enhance the efficiency, integrity, and quality of healthcare services within the Medicare Advantage framework.