Are they smarter than their competitors or is something else afoot?
Humana, Inc. faces new scrutiny from the Justice Department over allegations it has overcharged the government by claiming some elderly patients enrolled in its popular Medicare plans are sicker than they actually are.
The privately run Medicare Advantage plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. By contrast, under Medicare Advantage, the health plans are paid a set fee monthly for each patient based on a complex formula known as a risk score. Essentially, the government pays higher rates for sicker patients and less for those in good health. - NPR
On the surface it may appear there is nothing wrong. The government taxpayer SHOULD pay more for sicker people.
But who defines "sicker" and how is that assessment made?
Therein lies the problem.
(Dr.) Olivia Graves alleges that a Humana medical center had diagnosed abnormally high numbers of patients with diseases such as diabetes with complications that boosted Medicare payments — diagnoses that "were not supported by medical records." Graves alleges that Humana knew about the overcharges but took no action to stop them. Humana has denied the allegations.
And in early February, a federal grand jury in West Palm Beach, Fl. indicted Dr. Isaac Kojo Anakwah Thompson on eight counts of health care fraud. He's accused of cheating Medicare out of about $2.1 million by inflating risk scores of some Humana-enrolled patients.
Regardless of who you believe, ultimately it is the taxpayer that loses.
hat tip to Holly Robinson for this find.