Insurers accused of $50B fraud connected to Medicare Advantage plans

Private insurers who offer Medicare Advantage plans may have defrauded taxpayers to the tune of $50 billion between 2019 and 2021, a report from the Wall Street Journal shows. 

According to WSJ journalists, Medicare Advantage made “hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments,” including for deadly illnesses where patients received no care and for conditions that “people couldn’t possibly have.” 

The newspaper cites an analysis of billions of Medicare records for their determination. In some cases, neither the patient nor physicians seemed aware insurers were billing the Centers for Medicare and Medicaid Services (CMS) for the dubious services. 

Medicare Advantage plans are offered to seniors covered under Medicare for a premium, marketed as a way to expand the coverage of services and present them with more options. However, since their inception, these plans have been subject to scrutiny for denying necessary care while covering alternative therapies, like acupuncture, using a coordinated care reimbursement model. 

Despite being touted as advantageous, the upfront cost to enroll—given that coverage is largely determined by private insurers—may not add up to additional value for many patients. The number of patients covered by these plans has only gone up over time, and more than half of Medicare enrollees now utilize Advantage plans. 

The full story from the Wall Street Journal is available below.