CMS may punish providers that steer patients into ACA plans to boost reimbursement

CMS is asking for comments on what it should do about healthcare providers which steer Medicare and Medicaid-eligible patients towards marketplace plans in order to receive higher reimbursement.

The agency’s message appeared to be targeted at dialysis centers, saying in a press release all of those Medicare-enrolled facilities had been sent a letter about the announcement.

“Ensuring access to high quality patient care is a top priority for us. We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” said CMS Acting Administrator Andy Slavitt in a press release. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of marketplace coverage for everyone.”

UnitedHealth sued dialysis chain American Renal Associates Holding for these exact reasons, alleging the company directed patients to sign up for UnitedHealth plans on the insurance exchanges, with a charity, the American Kidney Fund, picking up the cost of their premiums.  

Concerns have been voiced by other groups this year. In February, the Blue Cross Blue Shield Association said its heard stories from members of nonprofit foundations and advocacy groups steering patients away from public programs to private coverage, as part of comments arguing against a suggestion in CMS’ notice of benefit parameters in 2017.

In its request for information, the agency hinted at several ways it could punish those steering providers, including ways to “prohibit or limit premium payments and routine waiver of cost-sharing for qualified health plans by health care providers, revisions to Medicare and Medicaid provider enrollment rules, the imposition of civil monetary penalties for individuals that fail to provide correct information about consumers enrolling in a plan, and potential changes that would allow issuers to limit their payment to health care providers to Medicare-based amounts for particular services and items of care.”

The CMS announcement noted that it’s left up to health insurance companies whether or not to accept third-party payments of premiums by providers like physicians, medical facilities or non-profit groups, though the arrangements are discouraged.  

Health insurers welcomed the CMS attention on the issue. America’s Health Insurance Plans spokeswoman Clare Krusing told the Wall Street Journal that steering patients away from Medicaid and Medicare is a “direct conflict of interest for providers” which are arranged “with the sole intent of increasing their own reimbursement.”