What Health Insurance Corporations Do

When given a chance to operate the entire payment package, what do Health Insurance Companies (HICs) do? For the past 8 years HICs have been given the freedom to operate Medicare Advantage - the high prestige seniors plan from CMS.
  1. HICs helped design the complex payment formulas for MA
  2. HICs found a way to upcode higher patient complexity for MA patients
  3. HICs shoveled in the profits using the design that they helped to shape their way
The Center for Public Integrity indicated, "For instance, audits of six plans found that health plans couldn’t justify payments from the government for 40 percent or more of their patients. The resulting overpayments were pegged at nearly $650 million for 2007 alone — just for those six plans."

When is it "gaming the system" and when is the line crossed to fraud?

The inconsistencies in HIC, GAO, and CMS efforts span the range of health care delivery. There is a pattern to the result. Some payment formulas benefit those with many billions while other payment designs penalize those with far less - like small health operations. One side helps those in need and the other side helps themselves.

Insurance companies in their role as payers have a great track record - deny and delay payment to those who do provide services. Turn about should be fair play. Why does CMS not deny or delay payments to insurance companies overpaid for Medicare Advantage plans? Given the magnitude of the problem, why has CMS not suspended, reduced, or otherwise reformed the program?

Physicians get blamed for upcoming in wave after wave of media blitz, yet insurance companies do mega-upcoding worth 70 billion more in Medicare Advantage dollars and few hear about it?

Medicare Advantage Seniors are urban and are often better off with a wide range of health, eye, dental, and other benefits. Contrast this with Medicaid patients that get the most restricted care packages and often have to beg to get care and appointments?

And where are the priorities of GAO - the government watchdog. It makes me mad when GAO targets rural hospitals for a measly 500 million in savings, due to what GAO brands as "overpayment." But GAO has failed for 7 years to audit insurance companies making 12 billion a year too much

Investigations by the Center for Public Integrity, CMS, and now GAO

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Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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