In 2021, the United States settled a lawsuit against California health care provider Sutter Health for $90 million. According to the suit, Sutter siphoned government money by falsely labeling temporary conditions as chronic, pressuring physicians to add unnecessary conditions to charts, and even revising patient records behind doctors’ backs.
Sutter’s alleged misrepresentation of its patients’ health isn’t isolated. So-called “upcoding” for Medicare Advantage (MA) beneficiaries costs the federal government an estimated $10 billion to $50 billion each year. But upcoding and other forms of fraud are just a small slice of the waste happening in MA, a privately-managed, publicly-funded alternative to traditional Medicare for older Americans. Over the next decade, taxpayers stand to lose hundreds of billions of dollars due to faulty rules that overpay MA plans and providers.
Some rules are baked into Medicare and will require Congressional action to change. But, according to our latest research, the Centers for Medicare & Medicaid Services (CMS) has immediate authority to save $500 billion by adjusting its approach to estimating MA patients’ health risks. On the whole, MA beneficiaries are less sick than plans claim and healthier than people in regular Medicare, meaning CMS can cut costs without cutting care.
Read the full article at The Boston Globe.
This article was produced by Footnote in partnership with Brown University.