What is the difference between Medicare Advantage and Medicare?
They’re two sides of the same coin. By choosing standard Medicare, people can visit any doctor they want. But they may have to buy supplemental insurance to cover gaps in what Medicare will pay for. This option is called “fee-for-service.”
By contrast, Medicare Advantage plans accept a set fee from the government for covering a person’s health care. The plans may provide extra benefits, including gym memberships and eyeglasses and cost patients less out of pocket than standard Medicare. Medicare Advantage is growing rapidly and now serves about 16 million people, about a third of all people on Medicare.
I'm a taxpayer. Why does this matter to me?
It matters because it costs taxpayers $150 billion a year. Medicare costs are threatening to swamp the federal treasury and policymakers agree the program can ill afford waste and billing abuses. Young people should care about this spending so that Medicare will be there for them when they need it.
What are risk scores?
A risk score is a formula the government uses to pay Medicare Advantage plans. The system is supposed to pay higher rates for sicker patients that are likely to require more costly medical services and less for healthy people.
Why were risk scores adopted?
Congress wanted to make sure health plans wouldn’t shy away from taking sicker patients who could cost them more to treat.
I'm covered under Medicare Advantage. Can I look up how my doctor uses risk scores?
No. The process goes on behind the scenes and it’s so complicated many people in the health care industry don’t fully understand how it works.
As the baby boomer generation ages, isn't it possible that the U.S. population is just sicker and requires more costly care?
It’s hard to say definitively without knowing a lot of medical details about individual patients. The government has not made this sort of data available. We are hoping that our lawsuit will shed some light on this.
What does this alleged overbilling mean for Obamacare?
The Affordable Care Act is using risk scoring and some policy experts worry that the system will prove extremely difficult to police — especially given the government’s history with Medicare Advantage.
Is there any chance of recouping any of the $70 billion in "improper" payments?
The Centers for Medicare and Medicaid Services, which runs the program, has broad authority to recoup overpayments, but has shown little interest in doing so. Instead, health plans suspected of overbilling have paid little penalty and can count on the government to keep their identities secret.