Most large Medicare Advantage insurers, including UnitedHealth Group, Kaiser Permanente and Humana, have been accused of fraud by whistleblowers, the US government or the Inspector General of the Department of Health and Human Services (HHS). I asked Maura Carley, CEO of Healthcare Navigation, LLC, how this happens and why it matters to all of us.

The federal government pays Medicare Advantage providers an amount for each enrollee. The sicker the patient, the more the government pays. But insurers get to pocket any money not spent on the enrollee’s care and administrative services. That’s where, according to government authorities, too much creativity in documenting risk factors has occurred. Recent lawsuits allege that Advantage companies are making patients’ health look worse so the companies receive more government money. The insurers have denied the accusations.

An incorrect diagnosis on your record is unlikely to cause you harm, but when the government overpays, we all end up paying more. By one estimate, Medicare Advantage overbilling could cost taxpayers as much as $25 billion—more than NASA’s budget or that of the FBI.

What to do: You can access your medical records through electronic medical record providers. Periodically review your record. If anything appears incorrect, raise it with your doctor and ask that it be corrected. If you suspect your insurer is engaging in fraudulent practices, report it to HHS at 1-800-HHS-TIPS.

P.S. The annual Medicare enrollment period is coming up. See our September 1 issue to learn about your options and how to make the right choice!

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